Abused foreign doctors enrich US hospitals, harm Americans →

Physician reveals how US exploits J-1 visa doctors for cheap labor—resulting in doctor suicides, medical mistakes, and patient deaths.

Dr. Corina Fratila: In this completely foreign country, I came in pursuing a dream—and you’re let loose in a very high risk, intensive care unit, critical care unit, taking care of all these people being responsible for all these lives—having almost no idea what you’re doing.

Then the night ends up with this person coding, the other person coding, and you end up sticking yourself with a big-ass needle and getting who knows what? You started the shift at eight in the morning, and then you would finish the shift at four, five in the afternoon, the next day. So, that’s 24 plus 10? 34-hour shifts times three, that’s 102 plus in between, of course, you would work regular hours.

Dr. Pamela Wible: 126 hours per week.

Dr. Corina Fratila: About 126.

Dr. Pamela Wible: Were you working with mostly J-1 visas?

Dr. Corina Fratila: I’m Romanian, I had two of my best friends, one was Italian, the other one from Kosovo. People from Germany, from Lithuania, from Serbia. You come here to get training. You come here to get away from whatever political system or whatever stuff is going on at home—to pursue a dream. You come here on a J-1 visa. You end up in this residency program that throws you to the wolves in the ICU. The after you’re done with residency in order to stay and finally maybe build a family, or make a living and be a real doctor, you have to go to an underserved area for seven years where you don’t know anybody. Again, start all over and go through this purgatory in order to eventually be able to go wherever you would like to set up.

My residency program, I thought they were good to me, they were good to my friends. I think it’s just the system. The way they pull somebody out of nowhere and just throw them in the ICU. I thought that was extremely traumatic—that’s extremely irresponsible.

Eating was not at the forefront of anybody’s mind. Or sleeping. Of course, when you were on call in the ICU, you didn’t even hope to sleep. When you’re on call on the regular internal medicine floor, then you would sleep maybe for 15 minutes before a nurse would call you to tell you that patient needs an enema or a Dulcolax. You had to sleep with your beeper, you had to be . . .

Dr. Pamela Wible: Ready to jump.

Dr. Corina Fratila: Ready to jump, yes.

Dr. Pamela Wible: Do you think as a result of this working 126 hours, poor sleeping and eating, and poor supervision for some circumstances that you and others were placed in, do you think patients were harmed by medical mistakes?

Dr. Corina Fratila: How can you even think straight after even after 12 hours of nonstop work. You’ve been in a sleep-deprived state for so long. I don’t even think I know what mistakes I made. I didn’t have time to process all that. I’m sure that mistakes happened not only every day, but multiple times a day.

Dr. Pamela Wible: In the ICU?

Dr. Corina Fratila: Yeah.

Dr. Pamela Wible: Life-threatening mistakes for some people.

Dr. Corina Fratila: Absolutely.

Dr. Pamela Wible: Did you question why this was happening?

Dr. Corina Fratila: I didn’t question it. I just thought I had to survive. I just had to make it. How could I start questioning? This is what I think now—if I stopped and started questioning, I wouldn’t have been able to go on. Then I would have had to go back to my country. My parents would have asked, “Why are you back? What happened to you? Why are you changing your mind after you invested so much in this? Now you’re just giving up?” There was no way. I mean, I had to finish it. I had to start and finish, and I had to go through it. What questioning? This is the system. Who can afford to stop and question? And then, if you start questioning, what options do you have as a foreign medical graduate? “If you don’t like it, go back, okay? You don’t like it? You came here by your volition, you don’t like it? Go back. Who’s stopping you? We’re not stopping you. We have tons of other medical residents lined up. Other foreign graduates lined up to take your spot.”

I think now that if myself or one of my loved ones end up in an ICU, I would consider them dead. I mean, if they’re in such a situation that they’re that sick and they end up in an ICU with fresh residents and interns, I would just close the case. I would be, “Okay, there’s no hope of surviving here.”

Dr. Pamela Wible: How tragic for the resident to be an accomplice in poor medical care, possible death of a patient, and for patients to come to the hospital expecting that they can get good care, yet this is the norm in teaching hospitals.

Dr. Corina Fratila: Yeah, I’m pretty sure.

Dr. Pamela Wible: I know a lot of J-1 visa suicide cases, some fired from residency and deported back to their countries. In residency, people are abused. I just call it abuse and human rights violations. Do you agree? Do you think this is in the realm of human rights violations for patients and residents to be treated this way? This level of sleep deprivation?

Dr. Corina Fratila: Well . . .

Dr. Pamela Wible: Or you think I’m too harsh?

Dr. Corina Fratila: I don’t think you’re harsh at all. I’m surprised that you’re the first person to ever raise this issue. I just learned yesterday that in Japan companies start investigating human rights violations when their employees work over 60 hours a week. So I don’t see in what way working 126 hours or 80 hours a week is not a human rights violation.

Dr. Pamela Wible: That’s two to three full time jobs, right?

Dr. Corina Fratila: Yeah.

Dr. Pamela Wible: A full-time job is 40 hours a week. So 126 hours a week, you’re working equivalent of three full-time jobs in a foreign country with people on the edge of life and death. Does that seem kind of extreme or unusual to anyone listening? Or is it a revelation? Sometimes I feel like when I share this, it’s a revelation to the person who’s reflecting on it. You know like they never thought about it that way.

Dr. Corina Fratila: Yeah, so I think it’s a reflection of the health of this country. A reflection of the culture on health. If we cared (I‘m an American citizen by the way) if we cared about our health, these things wouldn’t be happening. If we cared more about health, we would ask when we have our loved ones in the ICU, in a teaching hospital, we would inquire, ”How much training did this person have? Where is the attending in charge? Where is the person who did a specialty in critical care? Where are they? Why is my father under the care of . . .”

Dr. Pamela Wible: Of a woman who just arrived here from Italy just learning English. Is there a language barrier too?

Dr. Corina Fratila: Of course, yes of course. Especially the first few months . . .

Dr. Pamela Wible: The first few months, somebody here who doesn’t even have a complete handle on English is working in the ICU . . .

Dr. Corina Fratila: Sleep deprived . . .

Dr. Pamela Wible: For equivalent of three full-time jobs, getting paid minimum wage, with American citizens who are probably the ones hooked up to the ventilator entrusting their care to these people. And hospitals allow this, condone it, and make money from it. How do you feel about that?

Dr. Corina Fratila: It’s beyond appalling. It’s like the worst nightmare that you could imagine. And how can there be any physician-patient trust? How can you build a healthy system? How can you have anybody have any trust in healthcare when when the foundation of healthcare is completely rotten? Why would we expect to be healthy? Why would we expect our patients to be healthy? Why would we expect the whole nation to be healthy? When this is the foundation of teaching doctors . . .

Dr. Pamela Wible: None of these people coming here expected to be placed in such an unfair situation, that’s quite scary.

Dr. Corina Fratila: Yeah, it’s traumatic.

Dr. Pamela Wible: So you obviously were caring for people who ended up dying on your shifts.

Dr. Corina Fratila: Sure.

Dr. Pamela Wible: Is there any help when you lose a patient? You have to tell the family. You have to deliver some bad news . . .

Dr. Corina Fratila: There was no support, there was no such thing. You’re supposed to toughen up and just move on with your day. Of course you have people dying. That’s why you’re a doctor. People will die. Right? You’re just supposed to be tough and just move on. Who cares that you’re going to have post-traumatic stress disorder for the rest of your life. That’s not the hospital’s problem. That’s going to be your life. It’s your responsibility. No?

Dr. Pamela Wible: Do you feel like you have PTSD from things that you saw?

Dr. Corina Fratila: Oh, completely. I lost my sleep 20 years ago. And it all roots back to the trauma in residency.

Dr. Pamela Wible: Which has lifelong implications for not just your mental health but probably physical health.

Dr. Corina Fratila: Absolutely. Panic attacks, anxiety, depression. I’ve never had any of these problems before. I didn’t talk about it to anybody because the stigma associated with mental health. I felt if I talked to anybody I would be considered weak and maybe I would lose my residency position.

The beginning was very hard because the phone calls, specifically. You know it’s much harder to understand somebody on the phone than it is in person. You can’t really read their lips or you can’t really read their facial expressions. So I remember the first phone call that I got. I got paged when you still used to carry those pagers. So the nurses would page you and then you saw a number you had to call the number back.

The nurse at the other end of the line, who was also a foreigner, somebody from the Philippines would tell you something in her Filipino accent, and that would go into my Romanian ear, and at the end I was too embarrassed to say I didn’t understand. I just said thank you. I hung up the phone. Once I hung up the phone, I realized I had no idea what she just said to me. I had no idea. And I had to somehow figure out what she meant to convey.

Dr. Pamela Wible: How did you do that?

Dr. Corina Fratila: I called the number back.

Dr. Pamela Wible: And . . .

Dr. Corina Fratila: And I got a different person.

Dr. Pamela Wible: With a different accent? Into your Romanian ear . . .

Dr. Corina Fratila: So that first phone call, it’s still a mystery to me. My first phone call as a medical resident, I still don’t know what the nurse wanted to tell me. So I hope that poor patient made it. The one that she was calling me about, that she didn’t die, you know? But, I mean that was my first instinct. To just pretend like I understood, say thank you, hang up and then realize it—I was lost.

Dr. Pamela Wible: Probably not the only one who’s feeling that way.

Dr. Corina Fratila: Most likely not the only one. Most likely one of the thousands.

If you are a physician struggling and need confidential help, please contact Dr. Wible here.

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Physician PTSD—5 tips to disrupt the cycle →

Pamela Wible: Today we’re gonna talk about physician PTSD. Sydney, you’ve been working with physicians with PTSD for nearly a decade and just came back from a personal retreat where you spent four days with a very successful emergency doctor suffering from PTSD. I’m really curious what you’ve learned.

Sydney Ashland: What I’ve learned is that it’s a far more pervasive issue than anybody is even talking about. We hear so much about physicians living very highly-stressed lives with a lot of pressure, but we really don’t talk so much about the fact that many are living in secrecy with their PTSD, because it can be a career killer if you acknowledge that you’re suffering with something like that. The biggest thing I’ve learned is that it’s a far more serious issue that is very pervasive than I ever knew.

Pamela Wible: So underreported and not really talked about in medical circles. I didn’t even realize this was a problem until I started hearing from physicians who had very clear PTSD symptoms on the phone as I was talking to them on my suicide helpline. Looking back over the last 10 years, do you notice any themes as far as what specialties are at highest risk?

Sydney Ashland: Highest risk are emergency physicians, anesthesiologists, and surgeons. Those are the three that I most commonly work with that have recurrent or even complex PTSD symptoms. Many physicians hide their PTSD under the labels of anxiety or OCD. You’ll hear physicians joke. “Oh that’s my OCD.” Well, it’s not really their OCD, it’s their PTSD—their trauma. I listen carefully now when somebody starts talking about anxiety, panic attacks or OCD, because often those are covers for post-traumatic stress disorder.

Pamela Wible: I’m sure you’re aware of my complete disgust for the term burnout, which I also think is a cover for a lot of the mental health issues that physicians are legitimately suffering from.

Sydney Ashland: Exactly. When I started to talk I was going to say we’re used to hearing about physicians who are burned out. I don’t want to perpetuate that phrase so I avoid it. It’s a word that everyone nods their heads and approves of, yet if you start talking about the very real life-altering and disruptive energy of post-traumatic stress then people get far more uncomfortable.

Pamela Wible: What is it about medicine that causes this PTSD, do you think?

Sydney Ashland: First and foremost, a lot of medical conditions in the ED and OR are trauma-based. You know, someone gets injured, someone is severely ill and so there’s a lot of trauma in the family and internally with the patient when they’re in a high-drama situation. Makes sense that those traumatic situations can induce a trauma response in physicians.

Another cause is the training process for physicians. They are habituated in treating themselves poorly, being expected to operate at tip-top standards when your sleep deprived, hungry, haven’t relieved your bowels in a few days to get graphic. You know all the things that physicians put themselves through in order to be at the top of their class or be acceptable when it comes to rotations or residency. When you treat yourself poorly, you’re not as resilient. You don’t have the internal resources and tools at your beck and call and so then when a traumatic situation presents itself, you don’t have the resources to deal with it and you get sucked into that trauma response where adrenaline starts flowing, your reptilian brain kicks in and you’re in the fight-or-flight or freeze mode.

Physician with residency-induced PTSD shares her experience below. View full interview here.

Pamela Wible: So it’s definitely the exposure to suffering and death in patients, especially when there’s unpredictable trauma like gunshot wounds, car accidents (which of course as a family doc I’m not exposed to such horrific suffering and death). When doctors are dealing with mangled bodies and potential death of toddlers during their shifts—it is traumatic. You’d have to be like a sociopath not to feel some of this pain. And medical training is rampant with human rights abuse where you’re working these people the equivalent of two to three full-time jobs without work-hour restrictions that allow them to sleep, eat, and go to the bathroom. Compartmentalization takes over through the medical education process in order to succeed at work. They’re hyper-compartmentalizing emotions and their home life and all these things and so I think sometimes it only takes one next gunshot wound or one next traumatic experience to kind of put them over the edge, yet everyone has seen them as sort of normal up until that point, right?

Sydney Ashland: Right. I’d say they’re very close to the tipping point at any one moment and so it doesn’t even take the perfect storm to bring this into a profound reality for them, where they have a trauma response. And so yes, exactly as you’ve described it is perfect.

Pamela Wible: In a bit I want you to address some of the things that physicians can do if they’re suffering with these symptoms, but I’m very curious if you find that nurse practitioners and PAs and other health professionals are at risk as doctors are? Are they in a unique category themselves?

Sydney Ashland: Depending upon where they’re working. I have definitely spoken to nurse practitioners who work in the ED or the OR who are more prone to having PTSD as well. However, I would say that most PAs and nurse practitioners and other auxiliary staff that are right there in the traumatic event don’t have the same level of responsibility as a physician. That’s not to minimize the effects that seeing a gunshot wound or a child abuse case. That can be traumatic for anyone and everyone. But if you are in a position where the buck doesn’t necessarily stop with you, then you are less likely to feel isolated and in that isolation have a traumatic response. But certainly there are nurse practitioners and PAs who work in the OR or ED who have PTSD as well.

Pamela Wible: The training regimen for nurse practitioners and PAs is sufficiently different than physicians in the length of their training and again, the responsibility that they have so that at least at the retreats that I’ve held when I’m sitting for five days with an array of physicians, medical students, nurse practitioners and PAs, I definitely notice a difference between the level of PTSD in medical professionals. The longer that they’ve been in medicine it seems the more traumatized they are versus let’s say first and second-year medical students and the nurse practitioners who even if they’ve been in a career for a long time seem to be sort of overwhelmed hearing the traumatic stories of physicians in the room.

Sydney Ashland: I’d say for nurse practitioners and PAs their training is much less toxic and so they may suffer more from PTSD as a result of the dysfunctional environment in a hospital setting. For example, a malignant program with lots of toxicity and politics and they have a hard time maneuvering those waters while at the same time dealing with really high-risk medical situations. Then they’re more prone to the PTSD. Other non-physician training programs are much more benevolent and much more respectful in many ways for the people being trained so they don’t come with the same level of stress that most physicians do.

Pamela Wible: In what ways are you available for physicians, PAs, nurses, even EMTs who might be suffering from PTSD?

Sydney Ashland: I’m smiling from ear to ear because I am available in so many ways. I’m really committed to meeting people where they are at. I often have Skype sessions or phone sessions with people at very early hours or late hours depending upon what their time zone is so that I can accommodate them. My work life is very unpredictable and erratic and I like it that way. During midday when other people are in the office I might be out taking a walk, and then at the end of my day or early, early in the morning, I’m engaged with people who are really suffering with PTSD so that I can accommodate their hours. I also work on the weekends, but I am so accommodating. I have people who text me, people who email me so that we can stay in close communication, because I think that’s very important. PTSD is not something from my perspective as a physician coach that can be treated with once a week, 50-minute session in the therapist office.

Pamela Wible: PTSD is not really a scheduled condition.

Sydney Ashland: Exactly. And I often require people to be seeing a therapist or psychiatrist so that they can have medication if necessary or have a licensed professional dealing with them in their hometown environment, but as the coach and consultant that I am, what I love is my flexibility to be available so that I can get a text where somebody is really struggling at work and getting ready to go into OR. Can you help me find my center? And I’m right there. I’m on it. I’m either texting, I’m emailing. I even have someone who is stressed out enough that talking or emailing, all of that feels like too much pressure and so they’re writing me letters from Canada and it just tickles me because that is meeting them where they’re at, meeting them where their need is and so I’m happy to work with within anyone’s comfort zone, because that’s the way we need to treat PTSD.

Pamela Wible: And you’re actually even available to do a house call halfway across the country for multiple days at a time, right?

Sydney Ashland: I’ve done several personal retreats where sometimes it’s helpful for me to be able to come and actually see the workplace environment, see the home environment, especially for those people who have tried a lot of different interventions that don’t seem to be working. They’re on their third therapist and on FMLA. They’re really struggling to get back again and to really be able to see up close and personal what’s happening and schedule throughout the day, sort of, a care plan as it is for them to be able to take care of their needs before they get into a triggered response. So, they can slow down their life in such a way that they begin to notice the nuances of anxiety building and that trauma response being triggered.

Pamela Wible: I think you even told me that during the last personal retreat you actually attended the therapy session with your client, right?

Sydney Ashland: I did.

Pamela Wible: With her.

Sydney Ashland: I did. Yeah. And it was awesome. Their therapist was able to understand what my approach was and the resource that I could be, because therapists can’t be available 24/7 to talk somebody through going into the OR when they’re in cold sweat and hyperventilating. But I can really help with some of the tips I’m gonna give here in a few minutes with physicians finding that core place where they’re calm and where they can continue to move forward.

Pamela Wible: Before people hear about some of the tips that you have for them, I believe that everything that you provide is confidential. No paper trail. You’re not entering any of this into an electronic medical record are you?

Sydney Ashland: No, I am not. And I think that’s the beauty of me being a resource that is off the grid. I’m a coach. I’m a consultant and therefore, they don’t have to worry about mandatory reporting or that this is gonna get back to their supervisor. Certainly, I am wise enough to help people determine when they’re really at risk of hurting themselves or where they may be having intrusive thoughts that are desperate. Of course for sure we need a therapist and/or psychiatrist as a part of the team, because I think that’s another thing that’s really helpful with PTSD is to have some support because so often physicians work and live in isolation and so if you have a team that you know are all working on your behalf to help you heal this trauma, then it’s incredibly comforting and can make the difference.

Pamela Wible: So what do you actually tell doctors that say they only have a brief phone call with you, let’s just say? What are some practical tips that they can walk away with and actually implement to stop their PTSD symptoms?

Sydney Ashland: I have many tools that I’m happy to share with people. The top five general suggestions is first and foremost—don’t keep it a secret. You have to tell someone, whether that’s a spouse, a best friend, somebody you trust. Bring it to the attention of your therapist in a new way so that you’re not just there sort of processing generalized stress. You’re actually acknowledging that it’s at the level of PTSD. That’s number one.

Number two is having some centering and grounding practices in place so that you can become embodied again rather than what happens in that trauma response where you sort of leave your body and your in this very activated place where you can’t think clearly and our heart is beating fast, your breathing is shallow, you’re feeling a little bit confused or disoriented or feeling impulsive like you have to get out of the situation. I have some really helpful centering and grounding tools. I know Peter Levine, who is an expert in PTSD from Walter Reed Hospital, has some great recordings that help with centering and grounding as well.

Number three is slowing down the trauma response. Everybody wants to get rid of it, but getting rid of it is not the answer, because it’s really impossible to just will it away. What you need to do is really slow down the response so that you can begin to notice the nuances of what is it that exactly triggered me? Now that I’m triggered or activated what am I doing? What are the intrusive thoughts? What are my back doors that I fantasize about in order to get through? Once we slow it down, it’s sort of like stress eating. Those people that have found themselves in the kitchen eating an Oreo and they don’t even remember walking into the kitchen. How in the world am I standing here at the kitchen counter with an Oreo in my hand? Well, if you slow down that process so that you begin to notice every time you eat in your life, you will notice that you’re walking across the kitchen floor, that you’re reaching for the cupboard door, that you open the cupboard and pull the Oreos down and at any time in that process you can make a different choice. Well, it’s very true with PTSD as well. If you slow down the process and really pay attention to your center, your core, and begin to use some of those awarenesses to notice what’s happening, then you’re far more successful at not necessarily even needing to experience the full blown activation, but instead being able to disrupt it and not have a full blown event.

Number four is differentiating the physical versus the emotional response, because they’re both going on. Once you become aware of what’s happening physically versus what’s happening emotionally, then you can deal with each side of that coin.

Finally disrupt the PTSD cycle with specific interventions. And those interventions are unique to each person, because what activated this, what caused it in the first place, why we were susceptible to it and then deciding what is the appropriate intervention so that you’re not only slowing down the process, centering yourself, but you’re able to disrupt the process and bring in something else. It’s not about releasing PTSD, it’s about bringing in other tools and interventions that will disrupt the pattern and help you create a new pattern that then loosens the hold of PTSD.

Pamela Wible: That’s awesome. And I bet you’ve seen a lot of physicians very appreciative of your efforts and then able to maybe turn their life around and improve not only their professional lives, but probably their personal lives as well.

Sydney Ashland: Absolutely. Because a lot of times family members are aware that mom gets really quiet or dad disappears or it may be that you get irritated in your response to the disruption. And so people are aware that something is going on and they often then sort of walk on eggshells or try and ask questions. That only makes it worse because most people don’t wanna talk about what’s going on over and over and over in their head. They find that it only increases the stress of it rather than decreasing it. And so yes, it’s helpful with friends, with family. It’s life changing.

Pamela Wible: So if there is a husband or a wife of a physician or a physician themselves or maybe even a PA in the emergency department that would like to reach out to you, what is the best way for them to contact you?

Sydney Ashland: Best way is through my email, sydneyashland@gmail.com. Of course people also I know contact you a lot Pamela and sometimes you’re on the phone in the middle of the night helping someone. They can contact you if they’re in the midst of a crisis and wanna talk to someone and they can also contact me. Email is just the best way, because I have a fair amount of scheduled appointments and my schedule is erratic and so if somebody is just trying to call me every day at 4:00 PM they might not reach me, but if they send me an email and I find out what their schedule is, we will find something that works. Also my website is sydneyashland.com.

Pamela Wible: But if they have an urgent need or they’re really in the throes of PTSD.

Sydney Ashland: Then email me.

Pamela Wible: Squeeze them in urgently the same day sort of thing?

Sydney Ashland: Right. Oh, absolutely.

Pamela Wible: Okay. And I am also available as everyone I think knows 24/7 as long as I’m awake to answer and respond to anyone’s calls for free with physician mental health issues. So, thank you very much for sharing your insights and I look forward to having more people get the help that they need so they can practice medicine the way they always intended. Medicine is a team sport and physicians cannot approach this in isolation. To be a healer, we’ve really gotta come together and help each other.

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Doctors fear PHPs—why physicians won’t ask for help →

Doctors fear controversial program made to help them

Reposted from NBC affiliate KSDK in St Louis, Missouri. Author: Investigative Reporter: PJ Randhawa, Erin Richey
Many say a controversial program designed to help doctors with mental health issues is out of control, destroying careers and causing some doctors to commit suicide.
Dr. Gary Hammen admits that he was tired on the job.
In 2017, he had a newborn at home and a packed schedule as an anesthesiology resident, on top of a sleep disorder stemming from an injury he got serving our country as a soldier overseas.

But to him, the questions his supervisors asked crossed a line.

“They asked me, is this a drug problem? Are you sure you’re not using drugs?” he recalled. “I was floored.”

The questions came after months of exhaustion for Hammen.

Hammen says repeated, 24-hour shifts were taking their toll on his mental and physical health. Most weeks, he worked more than ninety hours and slept no more than four hours a night.

More than a year earlier, he met with his supervisors to tell them about his sleep disability, and offer them schedule recommendations from his sleep doctor.

He says supervisors promised, but failed to make any accommodation to his schedule or his sleep disability.

Weeks after his supervisors asked him about drugs, he got a call that made him think they didn’t believe him.

An organization called a Missouri Physician’s Health Program wanted him to fly to an addiction recovery center in another state, to be checked out.

Hammen couldn’t believe what was happening. “I had a bad feeling about it,” he said. “The whole thing just felt wrong.”

But he had no choice; colleagues warned him that if he didn’t follow the PHP’s requirements, he could lose his license and his career.

PHPs, or Physician’s Health Programs, are meant to help doctors with addiction or other psychological problems. But some, including Hammen, claim that doctors are sometimes falsely accused and getting help that they don’t need. They say the result drains their savings, endangers their licenses, and has even led some young doctors to take their own lives.

Nearly every state has a PHP. Some states have more than one. They started in the 1980s, often with close ties to the state’s medical boards or hospital associations. Medical industry professionals told 5 On Your Side’s I-Team that now big money is involved, and the lack of regulation turned a well-meaning measure into something that doctors fear even when they need help.

Dr. Wes Boyd of Harvard University is one of the skeptics. He used to work for a state PHP. Now he and others have raised concerns about these programs in the American Medical Association’s Journal of Ethics and in other respected publications.

“The physician is basically at the mercy of the PHP,” said Boyd. “There is no one outside the program looking at them, monitoring their practices and making sure that they’re really acting in a benevolent way.”

Boyd told us that when a PHP gets a tip about a supposed problem doctor, there is usually no way for the physician to appeal or dispute it. Instead, he or she must go to a “preferred” treatment center for evaluation. That center has complete authority to decide which doctors need treatment and how much.

Hammen made the flight to a treatment center, where evaluators made an unusual diagnosis. They said he had “provisional alcohol disorder,” something Hammen never heard of before.

“They hadn’t even talked to my wife to see if I drink. Most people wouldn’t make that sort of diagnosis without talking to some sort of outside person beside the patient,” said Hammen.

That diagnosis, Hammen thought, came from the fact that he told evaluators he and his wife shared a bottle of wine over the course of several dinners that week. It’s the only thing listed in the part of his evaluation describing his alcohol use.

Many of the treatment centers that PHPs refer doctors to are for-profit and specialize in addiction, even though doctors enter PHP monitoring because of stress and depression as well.

The I Team found many of the “preferred” treatment centers also donate money to the PHP trade organization: the Federation of State Physician Health Programs (FSPHP). Newsletters on the FSPHP website show several treatment centers are donors and exhibitors at FSPHP events.

Boyd told the I-Team that the bottom line motivates the centers to push doctors into treatment regardless of whether it’s really needed.

“Even in cases where there was no substance dependence, these centers come back and say, ‘You need to stay for 30 or 90 days of treatment,’” he said. “It is very hard not to think that financial motivations were behind the misdiagnoses.”

That can mean weeks of being unable to work, attending a treatment center that might not even offer services that doctors really need, with no way to get a second opinion or to choose their own care.

Even doctors who need help find the system difficult to navigate, with a high price to them and their community. Karen Miday once hoped that her son would get to help the community as a Cancer Specialist, but now he’ll never get that chance.

The words he left behind in a suicide note are so painful that she never took it out of the police department’s evidence envelope. But she read them to KSDK’s PJ Randhawa to show what he was feeling at the end of his life.

“That ‘I love you’ line stays with me,” she said.

“This is just the end of the line for my particular train,” Dr. Greg Miday wrote. “Earth wasn’t a great place for me.”

Dr. Greg Miday was 29 years old when he finished his residency in St. Louis in 2012. Friends and colleagues described him as bright, talented, and gentle. Under the surface, he also battled a drinking problem.

Miday’s last phone call was to the Missouri PHP. Karen Miday believes they had a chance to help him.

“I think all they needed to do was say, get yourself to a place of safety, you know, we’re behind you. That was all they needed to do,” she said.

Dr. Miday had been to one of the program’s approved out-of-state treatment centers before, where he followed the PHP’s requirements exactly. Then, just as he was about to start a new fellowship, he had a relapse.

Karen told the I-Team that he knew he needed help, but he also didn’t want to lose his new job. He suggested to the PHP that he could go to the outpatient program at a recovery center in St. Louis. This would let him keep his job and get treatment.

When Dr. Miday called the Missouri PHP, they said he must go to one of their “preferred” centers outside of the state. If he didn’t, the organization said, they would report Dr. Miday to the medical board.

“I think he thought there was no way out,” Karen said. “They have dual agency. It’s like being a policeman and a therapist at the same time.”

The list of approved facilities for Missouri physicians to get treatment includes just one in the state of Missouri. The nearest out-of-state option is in Lawrence, Kan.

“There’s no legitimate reason why they should have that handful of centers around the country that they prefer to use,” said Boyd.

“You start thinking after a while if there’s some diagnosing for dollars going on because now it’s not just substance use disorders, but now the “disruptive physician” and they’re talking about aging physicians,” said Miday.

Many doctors told the I-Team that the same lack of options that Dr. Miday felt is the reason that they fear contacting their local PHP when they really need help. That could put you at risk.

“If they’re afraid to ask for help, the chance that you’re going to get a doctor who shouldn’t be taking care of patients that day, goes up. And you won’t even be able to know what the chances that that’ll happen. Because nobody will say anything,” said Hammen.

The I-Team reached out to the Missouri Physician’s Health Program with questions, and even went to the home of program director Bob Bondurant, RN, to ask them. He declined to talk about the doctors’ concerns, as did the Missouri Medical Association, and the Missouri Board of Healing Arts.

The National Federation of State PHPs declined to answer any of our specific questions about how their programs work. Instead, they issued this statement:

“Physician Health Programs (PHPs) across the United States and Canada provide physicians and other health care professionals a resource to ensure they are healthy, can practice their craft and at the same time ensure public safety. Today’s physicians often suffer from stress and burnout. A smaller number develop substance use disorders and depression. We are a ready resource to physicians with such untreated conditions who would otherwise be at risk to the public an/or face loss of licensure by their state medical board. PHPs lessen the significant barriers that stand in the way of physicians asking for help.

Treatment is necessarily different for those in safety-sensitive professions, such as pilots and physicians; PHPs help physicians access care specifically designed to their needs. Our goal is to restore physicians’ lives and safely return them to patient care. Research as shown that the PHP care model has unmatched long-term consequences for substance use disorders. Additional research demonstrates successful graduates of PHP’s have a lower risk of malpractice.”

A few PHP nightmares published in my book: Physician Suicide Letters—Answered (free download):

Chapter 33—Adam

Dear Pamela, As a physician who struggles with suicidal thoughts, I appreciate what you do. Two years ago, I did a stint in a psych outpatient program due to depression, with great success. Since then I’ve moved to a new state and I find that I need support again. My medical director suggested I self-refer to the physician health program here. So I called (and didn’t give my name) and was shocked by how unhelpful they were. They described the process, which would delay returning to work. I’d be forced to comply with years of monitoring and pay for multiple evaluations and random drug screens. (Even though I don’t have a substance problem.) I may be mentally ill, but I’m not crazy! It seemed punitive and geared toward addicted docs with nothing to offer everybody else. I don’t think preventing suicide is on their radar at all. I would love to do more to advocate on this issue, but honestly I’m just trying to stay alive. ~ Adam

Chapter 34—Amy

Dear Pamela, I’m amazed at the punitive terms I’ve had to face in recovering professionally from a depressive episode for which I was hospitalized last year. One of my requirements is to be urine tested for substance abuse, despite multiple demeaning assessments that have rendered the clear verdict that I don’t have a substance use problem. I’ve had to attend costly treatments for “professionals” in which I am the only female in a group of male physicians who have had sex with their patients or have become assaultive with staff. Any efforts on my part to point out that I don’t quite “fit” are taken as further evidence of my pathology. I’m a single parent as well, so that each of these “treatments” I’m required to attend takes me away from my two children for extended periods of time. Throughout all of this, nobody has told me how common my feelings are—that a large number of doctors feel depressed and suicidal at times. Rather, I’ve been told that my actions are unheard of for someone in mental health and may preclude me from ever providing therapy again since “we tell patients to never give up hope, but you did.” Hopefully, in the near future this won’t be a taboo subject, and there will be places for those like me to seek responsible and confidential care. ~ Sincerely, Amy

Chapter 36—Susan

Hi Pamela, My ex-husband, also a physician, committed suicide one-and-a-half years ago. I have had my own episodes of depression with little support at work. (After taking three months off for a major depressive episode and to look after my grieving children, one of which was threatening suicide herself, I was told that I wasn’t carrying my share of the load at work and had a “boutique practice.” I’m a surgeon.) It is a long overdue conversation that I am trying to start here in Canada as well. We, too, have a physician health program which is in conflict of interest as it pertains to licensing and physician support. To this point, they have focused mostly on physician substance abuse and disruptive behavior. These seem to me to be late stages of physician mental health problems. I would like them to deal with issues before they get to those stages. But it is hard to do until we “re-humanize” physicians. Any resources I can use to break down the silence and annihilate the taboo are appreciated. ~ Susan

If you’ve been harmed by a PHP please leave (even anonymous) comment below. Free upcoming retreat for suicidal physicians (and those who have been suicidal). Contact Dr. Wible if you wish to attend.

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Dr. Wible responds to critics →

My request: Since 2012 I’ve dedicated my life to the doctor suicide crisis. Yet not everyone is in favor of what I’m doing. Some feel I’m unethical, insensitive, greedy—even a “nutcase.” I’ll now formally respond. I don’t need your compliments. I don’t need you to like me. Now is your chance to share your concerns (or things you hear others saying about me when I’m unavailable to respond). Be brutal.

I’ve organized all criticism I’ve collected over the years plus feedback received from my social media request above. Here are my responses.

1) Why respond to haters? I’m open to all criticism. If you didn’t care you wouldn’t engage at all. Even “haters” have something to teach. I’ve not always had time to address objections online so I’ve taken several days to collect criticism and formally respond. Conflict resolution requires honesty not ad hominem attacks. Caveat: I prefer speaking by phone or in person (online communication is prone to misinterpretation and devolves quickly—especially with emotional topics as suicide). For concerns that remain unaddressed, contact me here.

2) What is your motivation? My primary motivation is to end medical student and doctor suicides, eradicate human rights violations in medical training, and help all health professionals live their dreams in medicine. Why do I care? I lost both men I dated in medical school to suicide and nearly lost my own life to suicide as a physician. I feel compelled to understand why doctors are dying by suicide. Many feel oppressed—even abused—by their employers. Leaving assembly-line medicine and launching my own ideal clinic resolved my suicidal crisis. Restoring physician autonomy is one solution (among many) for doctors trapped in a toxic medical system. Plus I love liberating physicians to live their dreams and care for patients the way they always intended.

3) How can you do this as one person? You are modeling something that can’t be healthy—being on call for all the doctors and medical students in the country (the world?) who might consider suicide. If your work is to be sustainable (and all our lives depend on it, in some way) you need to be sharing your workload and training your replacements. Maybe you already are. Show us. You are correct. I can’t be on call for all medical students and doctors in the world—and care for myself. I never intended to be on call for doctors 24/7/365. I keep responding to emails and calls while training psychiatrists who will be providing telemedicine to physicians nationwide. Some are dedicating their entire practices to medical students and physician trainees (with housecalls for doctors—100% confidential!).

4) What about helping doctors’ wives or husbands? What about nurses and veterinarians? What about the opioid crisis? While I’d love to solve all the world’s problems, I’m one person. My goal is to remain congruent with my primary motivation (see question #2). By preventing doctor suicides and helping physicians live their dreams in medicine, life will be better for physician families—and patients will be more likely to receive ideal medical care. I’m hopeful that our success in physician suicide prevention will help suicidal nurses and veterinarians too.

5) You recommend DPC too heavily. DPC is not an option for everyone. Why are you pushing concierge medicine? Physicians assume I practice DPC or concierge medicine. I don’t. I accept insurance. I submit claims on behalf of my patients. I’ve been in network with most insurance companies in my private practice. I also welcome uninsured and I’ve never turned anyone away for lack of money since launching in 2005. I don’t charge extra fees. I’m not pushing any business model over another. When physicians need my business advice, I help them choose the right business and payment model for them. There’s no one-size-fits-all model. I’m currently working on effective solutions and interventions for specialists and hospital-based physicians. Stay tuned.

6) I thought you had a map of ideal clinics on your website. I can’t find it. Patients across the country often request referrals to doctors. I had a map on my site listing ideal clinics. I found it challenging to track all the clinics and—more importantly—I don’t certify ideal clinics and can’t guarantee that health professionals on the map are practicing medicine in a way that I deem safe. I no longer offer a map of ideal clinics. If you’re looking for an independent, holistic, or ideal clinic, just Google your town plus keywords important to you, then review websites and meet the doctor to see if you two are a good fit.

7) Recently a colleague asked what prompted me to consider leaving my job. I told him about your story and how little you spent to start your own practice. He responded with, “Oh, is she the crazy one?” Apparently you’d gotten a reputation. I responded, “Crazy or not, she’s a lot happier than you right now.” He didn’t have much to say after that. How do you respond when physicians call you a nutcase? My feelings aren’t hurt easily so I respond to attacks with genuine curiosity. Recently a 28-page Facebook PDF was leaked to me with vicious attacks (“Fuck her” “This woman is a nut job”) from a private forum in which mainly female physicians seemed to be seeking reinforcement for their views about my character (without ever speaking to me). Physicians rarely criticize me to my face. I’d welcome that conversation over dinner (my treat). Instead, doctors lash out with “she’s crazy” comments online. Physicians who cast vitriolic attacks on me are often unwilling to identify themselves by name therefore it’s challenging to engage in a real conversation. When invited for a phone call, they decline. Attacks without honest conversation are counterproductive. Of course, the most counterproductive physician behavior is infighting among doctors who attack each other (I don’t feel singled out). While third parties profiteer off physicians—divided and conquered—we perpetuate our own cycle of abuse by failing to unite amid common goals. I hope my responses here will forge relationships with those who have previously misunderstood my motives. Several older male doctors have apologized for calling me a “nutcase” and thanked me for my dedication to physicians so I’m ever optimistic.

8) How about not using the term “nutcase.” It is unprofessional and stigmatizes mental illness. You of all people should know better. (I am being brutally honest per your request). I avoid terms that stigmatize mental health. “Nutcase” is given as an example of the character attacks on me.

9) You are not a psychiatrist so what gives you the credentials to help suicidal doctors? I never intended to devote my life to suicidal doctors. When I began writing and speaking about doctor suicides, I was inundated with physicians asking me for help. Physicians tell me they’re grateful I’m available in the middle of the night when they’re struggling. I often get emails that start with the line: “I would have been one of your statistics, but . . .” and doctors share that my blog, video, or returned call saved their life. Although I’m not a psychiatrist, I’m compelled to continue given their feedback. Of course, I recommend physicians have a local psychiatrist. I do not give medical advice. I am not their psychiatrist. One reason my peer-to-peer support is so effective is that I avoid pathologizing doctors. I validate their experiences. I’ve heard hundreds of tragic accounts of punitive, pathologizing responses to doctors who need help and instead are harmed by PHPs and administrators ever ready to scapegoat our doctors.

10) What referral sources do you use for physicians in distress? My initial call may be two hours or a few minutes when I’m between patients in my clinic. Often I follow up with struggling doctors and may speak with their family members. If suicidal, doctors must be under the safety plan of a local psychiatrist. I don’t have names of local resources in each city though I’m amassing a list of psychiatrists available for physicians via telemedicine. For those with legal issues needing representation with an attorney, I have several I recommend. For those with malignant program directors, facing termination from residency, workplace sexual harassment, or in the midst of complex interpersonal relationships at home/work, I recommend a consult with Sydney Ashland who has great success with physicians in these situations. I favor referrals to those with excellent outcome-based results. I’ve personally met with all the attorneys and psychiatrists I refer to and have known Sydney Ashland since 2009 as her client. I’ve witnessed her success with my own complex patients and hundreds of physicians firsthand for more than a decade. Many professionals I utilize will fly out to see physicians personally or be available for emergency sessions by phone or Skype. Several offer free consultations or discounted fees for students. I’ve never charged any fee for my thousands of phone calls with struggling doctors and med students since starting my helpline in 2012.

11) My only concern was when you treated a murder-suicide in the same category as a doctor suicide. It was the one where a doctor murdered his wife then himself. To me that seemed more along the lines of abusive marriage turned homicidal. Why don’t you separate murder-suicides from suicides? I compile and investigate all doctor suicides regardless of whether preceded by homicide. To remain congruent with my mission of preventing doctor suicides, I avoid vilifying suicide victims—despite innocent lives sacrificed. After investigating nearly 1200 doctor suicides, I believe the cycle of abuse in medical training destabilizes doctors—particularly during residency. This cycle of abuse—often internalized by the victim and reinforced by our profession—is passed right on to their own family. I’m now aware of a Facebook group for domestic abuse victims married to physicians. If doctors were protected by labor laws and assured safe working conditions that protected their rights and encouraged non-punitive mental heath care, I bet there wouldn’t be so many neglected/abused physician spouses and children. Just a thought. Not excusing any crimes against humanity (whether perpetuated by hospitals or individuals).

12) What are the human rights violations you keep referring to in medical education? Extreme sleep deprivation, 80+ hour work weeks (many working more and forced to lie on hospital computers about their “work-hour violations”), lack of access to food/water, lack of HIPPA protection when seeking mental health care, lack of protection by ADA, invasive licensing mental health questions, censorship, sexism, racism, bullying, hazing to name a few.

13) What’s your problem with the word burnout? Burnout is 1970s slang for end-stage drug addiction—now weirdly applied to doctors. Physician burnout blames the victim not the medical system rampant with human rights violations that injures doctors—and patients. Physicians have the highest suicide rate of any profession and “burnout” distracts us from eradicating human rights violations that lead to physician suicide, PTSD, anxiety, depression—when our doctors are overworked, sleep deprived, bullied, hazed and mistreated in manners illegal in other industries. Meanwhile burnout is a cash cow for physician predators—all the burnout coaches teaching docs to take deep breaths and keep gratitude journals amid the abuse. Instead of eradicating abuse, medical institutions appoint “Chief Wellness Officers” who force “wellness modules” on the overworked while telling doctors they must have “burnout.”

14) Detail the ways in which you avoid publicizing the death of a physician, when the family asks that you do so. There have been 3 instances since 2012 when I’ve been asked by a family member to remove a public photo, post, or blog about a loved one as detailed below:

1) In 2016, a woman inspired by my work on physician suicide reached out to me. Her father—a surgeon in the prime of his career—died by suicide in the 1960s. After several emails and phone calls, we became friendly. She sent photos of her dad and requested he be honored in the Do No Harm film Wall of Remembrance. With her approval her father was also included in a few lines of a blog. When the Washington Post asked to publish my blog, she decided against including him in the article and the film. Her wishes were granted immediately by me and by the filmmaker.

2) In 2017, I published a RIP Facebook post about a resident in the week after his suicide. Upon the request of a family member I removed the post.

3) In 2018, I received a flurry of emails commanding me to take action in the aftermath of a physician suicide in NYC. One was from an executive at the hospital and others were from residents and their families who live and work with the victim who stepped off the 33-story building. I was told to lead a candlelight vigil for Dr. Deelshad Joomun. She was here on J-1 Visa and her family lives overseas in Mauritius (She is the second doctor from Mauritius to step off this same building in 2 years). I had no intention of inserting myself in the aftermath of her suicide, yet I was inundated by emails begging for my help. So I flew to NYC and led her candlelight vigil and 10-hour memorial exactly one week after her suicide. Read her eulogy here and article by her friend, a journalist with Refinery29 here. Turns out Deelshad was the third in a cluster of suicides at Mount Sinai and staff told me that if any reporters attended Deelshad’s service they’d be arrested. I was disturbed by the secrecy around her suicide. After posting her eulogy, I was contacted by her family who claimed she died in a car accident despite video surveillance from the rooftop. Some family members asked me to remove her eulogy and other family members requested I leave the eulogy online because “the world has to know how doctors are treated by the medical system in the US and I am wondering whether we have cause for filing legal action against the hospital.” After weighing censorship versus the need to honor suicide victims and hold hospitals accountable, I held firm in my posting of Deelshad’s eulogy.

15) Have suicides really been covered up by medical institutions and families? We’ve known about the high doctor suicide rate since first reported in 1858. More than 160 years later, root causes remain unaddressed—largely due to secrecy and censorship by medical institutions and families. Thankfully many families are now speaking out. Progressive medical institutions are discontinuing censorship policies around medical student and physician suicides and helping students and staff grieve in the aftermath of suicides.

16) Families have a right to hide doctor suicides. It’s a private matter. Have respect for the family. Approximately 400 US doctors die by suicide annually—the size of an entire medical school of students lost. This number—considered an underestimate by researchers—doesn’t include medical students dying by suicide. Each doctor (depending on specialty) cares for 2000 – 3000 patients so each year (do the math) more than one million Americans lose their doctors to suicide. Physician suicide is a public health crisis and must be treated as a public health crisis with accurate data, body counts, and real investigations. Families (and medical institutions) don’t have the right to shield the truth during a public heath crisis. We need facts.

17) Do you ever release names of suicide victims before the family is notified? I’ve never released a victim’s name before next of kin are notified. I don’t share detailed suicide stories that have not already been released by media or approved by family. I’ve not publicized information about physician suicides when families request this not be revealed. Police from multiple states have explained suicide protocol to me. In the aftermath of a suicide, the body is identified through a friend/family member/neighbor and/or police on a welfare check. Police secure the scene by removing firearms and then make a “courtesy call” to the family. They investigate, identify a suicide note if present, interview family, neighbors, witnesses, and write up their report that is available as public record through the Freedom of Information Act. All suicides are public record. Moving forward, I’m adopting policies that most media outlets use which is to report on suicides. I always do so after families have been notified.

18) If you’re going to be so cruel as to blame families for their loved one’s suicide, you really need to have ironclad evidence to back up your assertions. I have never blamed a family for their loved one’s suicide.

19) How do you support families in the aftermath of a physician suicide? I’m extremely close to many of these families. Most suicides in my presentations are from families that have granted permission and are thankful that I am sharing their loved one’s life. I started a Facebook support group for families who lost loved ones to suicide in medicine. I’ve facilitated support calls and even led all-expense paid retreats for family members in the aftermath of losing a loved one to suicide.

20) Why must you publish doctor suicide notes? Publishing physician suicide notes is gross and over the line. It is triggering and upsetting because so many of us have lost classmates and now you’re making money on that book. On their pain. That makes you like the Jerry Springer of doctors. In my book—Physician Suicide Letters—Answered, I have approval from all families that contributed notes. Few are actual suicide notes. Most are letters between me and suicidal doctors—still living. All book proceeds are used to prevent suicide, run the helpline, offer retreats to survivors and families. Doctors are great at documentation and they often leave clear reasons for suicides in their notes. To stop the doctor suicide epidemic, we must analyze their notes and take action to ameliorate the conditions leading to doctor suicides. Burying notes with victims does nothing to advance our understanding or prevent suicide. In India, doctor suicide notes are read on the evening news and those responsible for tormenting the victims are brought to justice immediately. Secrecy won’t solve a public health crisis.

21) You are not supposed to share how someone died by suicide. If we never studied the method of suicide, how could we prevent doctor suicides? Suicide methods vary by region and gender. Women prefer to overdose. Men choose firearms. Gunshot wounds prevail out West. Jumping is popular in New York City. In India doctors are found hanging from ceiling fans. Male anesthesiologists are at highest risk of any gender/specialty. Most die by overdose. Many are found dead inside hospital call rooms. Doctors jump from hospital windows or rooftops. They shoot or stab themselves in hospital parking lots. They’re found hanging in hospital chapels. Physicians often choose to die where they’ve been wounded—often inside hospitals. I don’t share gruesome details or sensationalize at the expense of accuracy. Just the facts. Without the facts, how are we to solve this crisis?

22) Media guidelines recommend the opposite of what Wible does—they say don’t use sensational words like “epidemic” or “crisis.” How can we solve a public health crisis if we can’t use the word crisis? Why minimize and censor a lifesaving conversation?

23) Publicizing suicide can trigger copycat behaviors in others. One hesitates to say such an awful thing, but she wanted brutal honesty. What if failing to use journalistic best practices to report on some of these physician suicides heightened the risk for some of those who were on the brink? One side effect of prescribing anti-depressants is suicide. Does that not mean we stop prescribing anti-depressants? No. One side effects of reporting on suicide may be triggering those on the edge. Does that mean we censor suicides? No. Censoring physician suicide for more than a century is not an effective awareness or prevention strategy. I’ve chosen a more honest (albeit controversial) method of addressing physician suicide by collecting real data and sharing lessons learned from more than one thousand case histories of doctor suicides. Media guidelines that censor suicides have undermined our ability to address this crisis. As scientists we must analyze each suicide and determine the actual reasons we’re losing our colleagues. My mother, a retired psychiatrist, used to ask me each day after work, “Have there been any copycat suicides today?” Her way of ridiculing the notion that breaking through the suicide taboo with the truth would harm doctors more than censorship.

24) Please focus on the causes of suicides instead of on posting so immediately and bluntly ALL the time about the suicides. I think it’s okay to do that sometimes, but a shift toward more energy on holding accountable those who generate the cultures or are complicit in them might be a better strategy. I totally agree.

25) Dr. Wible discourages suicidal physician from seeking psychiatric care. Untrue. Anyone who is suicidal requires safe and confidential psychiatric care.

26) You don’t use evidence-based methods in suicide prevention. The only evidence I need is feedback from people who claim something I did prevented their suicide. I do more of what helped saved their life. If someone claims a desire for self-harm from something I did (and I’ve never received such feedback), I’d avoid repeating that.

27) Dr. Wible reinforces the narrative that physicians with mental illness are not fit to practice medicine. She states repeatedly on her blog that if you have a history of anxiety or depression, you shouldn’t pursue a medical career. All potential medical students (and their families) must receive informed consent of the mental health risks of medical education and practice. Am I concerned when a premed student with a history of suicide attempts and IV drug use wants to pursue anesthesiology? Yes, and I share my concerns and advise them accordingly. Yet the choice to pursue medicine is their decision. Many physicians suffer from mental illness. Most are occupationally induced or exacerbated. All physicians require confidential mental health care. Since 2012 I’ve devoted most of my life to helping physicians with mental illness get the care they need so they can continue practicing medicine—safely. Mental illness does not equal impairment.

28) Dr. Wible implies that taking psychiatric medications is somehow a marker of personal or professional failure. Taking appropriate medication for psychiatric illness is never a personal or professional failure; however, when the majority of medical trainees are on stimulants, anti-depressants or both just to make it through the day, that is a marker for failure of the medical education system.

29) Why are you encouraging medical students to drop out? Dropping out of medical school is not a failure—it’s a legitimate option for anyone that doesn’t feel medicine is the right fit. Students should be helped, not hindered and shamed to remain in a career that increases their misery and risk of suicide.

30) I lost a great deal of respect for when you embraced clickbait-style marketing techniques. I think that you did it for good reasons… To spread your message far and fast. But you did it at the expense of weakening your credibility and that hurt the message itself. I voiced these concerns to you publicly and privately. I felt that you brushed me off and your fans rushed to your defense to shout down what I felt was a fair criticism. You are correct. I’m certain that I did not thoroughly respond to your concerns as evidenced by the fact that I’m having to look up the definition of clickbait marketing—desperate for attention, marketers are resorting to quick-hit emotional headlines to generate clicks—whether or not they actually have something meaningful to say. Absolutely I tried everything to get medical students and doctors to click on articles that I knew could help save their lives. My headlines are emotional (how could they not be when dealing with suicide?). After writing this article How to graduate medical school without killing yourself I got this letter:

“Dear Dr. Wible, I’m not sure you read your [Facebook] messages but feel compelled to thank you. I was finishing term two of med school and had a bottle of Xanax in my hand. I was ready, as so many of us are. I took three then three more and came across this link, “How to graduate medical school without killing yourself ” which I believe may have saved my life and a couple of close friends who are also suffering. I’m near the top of my class and praying for death to escape the trap I’m locked into. I was in true delirium from lack of sleep and fear of failure. Studying in my sleep and waking up every hour in panic. Med school is doable but why must it be taught in this format? I read your stories and I’m just in shock how many others feel like I do or I feel like they do. Please keep sharing. You are saving lives, friend. Chris”

After reading this letter, I spent $3000 boosting this blog on Facebook to medical students. I’ll spend any amount of money and create any headline that will save the lives of medical students and doctors. I have an overwhelming sense of urgency to reach these students. Put yourself in my shoes for a few minutes: I’m on the phone with a mom who lost her only child to suicide in med school and she tells me, “If my son would have attended your retreat, I think he’d still be alive” I’m thinking she’s probably right. So how the heck am I going to get all these med students to my retreats? I’ve spent at ton of money to reach these people. FYI: suicidal medical students get scholarships to retreats so spending thousands of dollars on marketing med students is a huge financial loss for me.

If clickbait marketing saves even one life, I’ll do it. Do the lives saved from clickbait headlines outweigh the risks of weakening my credibility? Would more people be alive if I used a more conventional academic headlines? Would Chris have completed his Xanax overdose without an emotional clickbait headline? I’ll have to ask him.

31) Using sleazy promotional techniques pioneered by multilevel marketers and internet pyramid scheme peddlers has so damaged Dr. Wible’s reputation throughout the wider medical community that if it were anyone else, I’d say the damage was irreparable. Even if her integrity is intact. Even if she has really given far more away for free than she has received via the ways she has set out to monetize, the perception that she has ‘sold out’ and is not what she purports to be is now widespread and it impairs her ability to have the impact she would like. I do believe that she could fix this. The very fact that she has bothered to ask what is wrong, why there are people saying such things about her, speaks to her capacity to correct course. Pamela Wible is a phenomenon. Her whole story, what makes it inspiring, is that she reinvents and breaks molds and pushes envelopes. She is radical. If anyone could radically redeem a damaged reputation, I think that it would be her. I pray it is so. My motivations are pure (see question #2). Don’t kill the messenger or lifesaving message over marketing techniques utilized with genuine intent to save lives.

32) You are making money off of human suffering. All doctors make money off human suffering. I’ve never charged a med student or doctor for mental health help. Never. I make money in my clinic by helping patients with human suffering like all doctors and by providing business strategy to help doctors launch independent practices. (please see deconstructing my finances at end).

33) Dr. Wible is wearing the wrong clothing, has the wrong hairstyle, offensive jewelry and has cultural appropriation issues. In 2013, I was first criticized for my clothing, hairstyle, and jewelry after my article “Why I’m Loving Private Practice” was published in a medical journal. In a letter to the editor, a male clinic manager in Chicago wrote:

“I don’t know about you but I don’t want to see my physician with frilly hair, dangly jewelry, Levis and clogs—look professional for goodness sake! Hasn’t she ever heard of the physician placebo effect? Look like you know something. You are not the patient’s mall shopping buddy, you are her physician.”

My response:

“The patriarchal medical model is becoming obsolete. The traditional doctor draped in a white coat is not so favored by patients. People today value authenticity over authoritarianism. My clients want the real me—the Pamela with frizzy hair, tribal jewelry, comfy Levis, and colorful clogs. A recent thank-you card reads, ‘It is so refreshing to meet a real doctor with a real personality.’ A man shares, ‘Well, I for one would love to see doctors in less formal wear. I hate the overly stuffy and holier-than-thou look of what should be bygone days.’ Times are changing. Patients don’t want one-size-fits-all medicine or cookie-cutter doctors. Let’s be real. Compassion, intelligence, and authenticity will always be more therapeutic than a placebo outfit.”

After my TEDMED talk on doctor suicide, I was chastised again for my outfit, hair, and jewelry. Meanwhile men get up on stage wearing backward baseball caps, ripped-up jeans, and flip flops and the audience bows to their expertise. When my necklace is the only ammunition my adversaries have left, maybe that means I’ve prevailed.

34) I feel like ripping the bindi off her face without a fucking clue what the significance of the symbol is. Shameful cultural appropriation of the Indian culture is extremely offensive and inappropriate. Your message is lost when you pull those kind of antics. Symbolism of Indian spirituality should not be a branding commodity. First, it was never my idea to start wearing bindis until medical school when my entire social circle were students from India. They encouraged me to wear bindis and their saris to parties. I dated 2 men from India and was engaged to one who I dated for 3 years. We were planning a wedding in India. His family in India wanted me to wear the bindi and traditional attire—even daily. I’m a spiritual person who subscribes to much of Hindu philosophy and they were thrilled that I was vegetarian, speaking in Hindi, singing the bindi song which I still know by heart. Now suddenly I am being disrespectful to an entire culture that welcomed me with open arms—encouraged me to dress this way everyday. I guess since we decided not to marry but remain friends, the bindi must be “fucking ripped” from my forehead by a female physician who doesn’t even know me. I’ve been told by Indian women doctors that I can only wear a bindi to an Indian function but not while advertising my “brand.” I’m not advertising any brand. I’m being me. I’ve been wearing glitter and sparkles and bindis since 1990 without any flak from anyone. Now that I’m on the taboo topic of doctor suicide, my 5 millimeter bindi is suddenly offending an entire culture.

35) You don’t dress or behave like the female doctors that taught me in residency. I’ve been told I’m not a “cookie-cutter” doc. Though casual in my appearance, I’m very conservative and cautious in my medical decision-making. I’m an eccentric, fearless free spirit at my core (and that makes physicians who prefer predictability and structure nervous). I’m also very loving and committed to people and causes that I hold dear. I will move mountains to help others.

36) Physicians undergo residency training because it’s absolutely necessary to practice medicine safely, competently. Telling people to try to find shortcuts through or routes around that process does not get them to the same endpoint as going through it properly. It is easy and expedient, to encourage people to enter practice with only a year of training, or to try a back door approach like opening an unsupervised NP practice in one of the states that allow that travesty. Far easier and faster and headline grabbing than seeking to impose higher standards on medical training with regard to resident wellness. Telling doctors to drop out and open their own clinics is an effective solution for some of those docs, but it ignores and even undermines the work that needs to be done to really fix the broken healthcare system. We agree the entire system needs to be revamped. We agree some doctors launching their own clinics without completing residency is an effective solution for them and their patients. There is a bottleneck in medical education that allows unmatched med school graduates to be unemployable in clinical medicine while NPs with lesser education launch independent clinics unsupervised. Unfair? Yes! While I’d love to wave a magic wand and fix the structural flaws in our medical training system, my first goal is to keep the doctor alive on the other end of my phone line. If there’s a way to help suffering physicians salvage their careers and practice medicine safely and competently after one or two years of residency in an outpatient primary care setting, I see no reason not to help. Regarding residency training, I strongly believe in personalized tracks. I shouldn’t be forced to do NICU and OB rotations as a family doc if I don’t intend to deliver babies. Another family doc who plans to work in rural Alaska can grab my NICU/OB months. Subjecting doctors to a one-size-fits-all residency training is not ideal to meet individual needs of doctors, particularly those who have left residency due to medical illness or abuse.

37) Here’s my only issue: focus on doctors not midlevels. The encroachment of NP/PAs on our jobs is a giant reason for doctor stress and discontent. They are taking our jobs, work a fraction of the time with a fraction of the education and all of the rights and privileges and very few of the restrictions and requirements we have. They attack our profession and insult us with the ‘heart of a nurse brain of a doctor’ campaign. I think the primary issue is frustration with a system that allows NPs/PAs to enjoy pay parity, practice independently without supervision with a fraction of the training of residency-trained physicians. Is it fair for PAs/NPs to enjoy physician pay with a fraction of the education? No. Is it fair for NP/PAs to launch independent practices with lesser education while doctors with far more education are prohibited from practicing independently in the same state? No. Should corporations motivated by greed replace doctors with PA/NPs? No. Should NPs be graduating from quickie online programs and bypass doctors who have 7+ years of training? No. None of this is fair and thankfully physician groups are actively combating theses inequalities.

My primary motivation (see question #2) is to end medical student and doctor suicides, eradicate human rights violations in medical training/practice, and help all health professionals live their dreams in medicine. The question is one of competency. Who is competent to practice independently without supervision? I know some residency-trained physicians with questionable competence who have harmed patients. I know some NPs practicing in ways I consider equally harmful. I know even more medical systems that force competent doctors/NP/PAs to work in 7-minute increments that certainly harm patients and undermine their otherwise competent style of practice.

I believe the safest medical care is delivered by someone with enough training/competence, time, and curiosity to solve medical conditions within their scope of practice. I wish health professionals weren’t pitted against each and that we could all work collaboratively. I’m on the front lines of helping individuals who are suffering mental health issues often from being forced to deliver big-box assembly-line medicine. Most health professionals who seek my help are doctors who have completed residency and want the autonomy to practice medicine the way they always imagined. A minority of physicians come to me having not been able to complete residency for a variety or reasons. Some PAs and NPs seek me out because they are fed up working in assembly-line medicine for the same reason as doctors. I help them find collaborating physicians or launch independent practices within their scope of license. Is this ideal? I don’t know. I’m working with individuals as they present themselves to me. I don’t have all the answers. I’m trying to keep health professionals alive and fulfilled in practices where they can care for patients competently outside of assembly-line medicine. The system seems to be rigged against doctors. I’m dealing with struggling individuals on a case-by-case basis. Some are not suited for independent practice and those who are I do my best to support them.

38) What’s your relationship with the Do No Harm film? Do No Harm is a documentary exposing the doctor suicide crisis by Emmy-winning filmmaker, Robyn Symon. I’m interviewed in the film along with many physician experts and families from all over the USA. The film honors nearly 100 doctors and medical students who have died by suicide from all across the globe. Though the filmmaker consulted with me at times when she had questions about doctors and suicides, Do No Harm is not my film. I’ve never received money from the filmmaker. The film was funded from grassroots donations via Kickstarter from concerned patients and physicians all across the world. I have no financial relationship with the film or filmmaker. I do not receive any proceeds from the film.

39) Were you banned from physician groups? Why? Details please. 1) In July 2017, I was banned from the Physician Moms Group—a Facebook group for women doctors who discuss everything from challenging cases to new business ventures. Women docs give and receive advice on book covers, clothing line launches, and share cute pics of their kids. I was banned for posting the Do No Harm film poster with this request: “Morbid post. Need help. We are designing film poster for Do No Harm film to prevent doc suicides and we’ve got an internal dispute about BEST angle for slitting one’s arteries for suicide. Here are two versions. Definitely appreciate any help. Specifically what angle would a doctor use? Thoughts?” An extremely lively conversation ensued with more than 150 thoughtful comments until I was banned for self-promotion.

2) On 11/8/14 after several medical student suicides were prevented by my blog How to graduate medical school without killing yourself (see question #30), I shared it on Student Doctor Network. Apparently I’m not allowed to post blogs (or excerpts from my blogs) on doctor suicide—even if information can prevent suicides of their own members on Student Doctor Network. So I was banned.

3) After the suicide of a former internal medicine resident and an anesthesiology resident (in which no grief counseling was offered) my book was banned from the Duke anesthesia department. An attending purchased 6 copies of my book Physician Suicide Letters—Answered to distribute to her residents. She was summoned to the office of the division chief who stole the books she had left for residents in the anesthesia workroom and told she was not to distribute these books to the residents. The mishandling of suicides at Duke (and my banned book) is now part of a federal lawsuit.

4) After the AMA invited me to deliver my TEDMED talk, I was disinvited shortly before the event because they were “uncomfortable” with the topic of physician suicide.

I am eternally grateful to TEDMED, Kevin Pho MD, Medscape, The Washington Post, and other major media outlets for never censoring me or my doctor suicide prevention efforts. I’ve never in my life been banned from anything before speaking out on doctor suicide. I’ve never been publicly criticized for my hair, jewelry, and clothing until speaking about doctor suicide and empowering physicians to break free from abuse. I’ve never been called cruel, told to fuck off by a physician, or had such vicious attacks on my character until I began speaking out about our doctor suicide crisis. And I’ve only been censored by other doctors (and mostly female physicians).

40) Deconstruct your finances. Detail the fact that you make zero profit from retreats and seminars and such, as I assume is the case. Give numbers with regard to physicians with whom you have spoken, for free, about their stressors etc. Detail volunteer work that you do in the tragic arena of physician suicides. My income: 1) Treating patients in my clinic since 2005 (without ever turning anyone away for lack of money) 2) Helping doctors and medical trainees who want business strategy and mentorship to create their ideal clinics through seminars and retreats. 3) Inspiring doctors and med students to live their dreams through speaking events. 4) Two books on preventing physician suicide and living ones dreams in medicine (100% proceeds to suicide prevention)

These four things fund my philanthropy: 1) Free helpline for doctors and med students. I’ve spoken to thousands of suicidal medical students and doctors since 2012 and I’ve never charged a cent (though I appreciate all the unsolicited donations). 2) Scholarships to retreats and seminars for medical students and residents. 3) $10,000 yearly scholarships to needy residents and med students to help them live their dreams in medicine 4) Doctor-suicide-related events like flying to lead memorials and candlelight vigils for physician suicide victims and free retreats I’ve held for survivors of doctor suicide.

In summary, I’ve never made money from suicidal medical students of physicians. I’ve spoken to thousands of physicians/medical students since 2012 related to their mental health and guidance on an array of other topics—for free. I earn money primarily from treating my patients and providing business strategy for physicians and trainees who want to launch independent practices. I am also now paid to speak on health care delivery and physician wellness. I live a simple life in a 900-square-foot house with no debt and no children. I have just signed the papers with my attorney to leave 100% of my estate to scholarships for medical students and physicians.



How to fall in love with your EMR →

Love your medical records

Excerpt from a conference call tonight on how to fall in love with your medical records—just in time for Valentine’s Day! Download and listen in to podcast below or read transcript for a journey through the history of the modern EMR—with fun solutions!

Once upon a time there was a doctor, a patient, and an index card. Here’s my dad and his box of medical records—all on 3 by 5 index cards in a recipe box.

Life was good. One doc with tiny handwriting—a man of few words—fit 30 years of a patient’s record on one index card. A friend told me she got an index card in some transferred records with 13 visits on the back and front of a 5 by 8 card and now she gets 8 pages from the podiatrist for an ingrown toenail—total insanity!

It wasn’t easy to separate doctors from their index cards. When an insurance company complained about his 3 by 5 cards, one old-time doc relented and switched to 4 by 6 cards. My dad always had his index cards with him in his shirt pocket—until his death, constantly taking notes (even during our phone calls!)

Don’t you wish you could have been a fly on the wall as they ripped the recipe boxes away from old-school docs and forced them to type on computers? Well, you’ll never believe this (and of course this would happen to me) . . .What are the chances that I would actually run into a brilliant anthropologist named John-Henry Pfifferling who actually followed docs around with a notepad for two years studying the index-card-to-computer transition? And he lived to tell about it!

As you might imagine physicians not only had resistance to EMRs but also to an anthropologist following them around taking notes on their behavior. The entire project was considered “too dangerous” because medicine just “wasn’t ready for anthropology.” Plus doctors and hospital admins found it difficult to believe that an anthropologist would actually be interested in modern cultures, particularly the profession of medicine and the transition to electronic records.

So I just read his 343-page PhD thesis from 1977: “Records and Revitalization: The Problem-Oriented Medical Record System in a Clinical Setting” that recorded the adoption of the problem-oriented medical record among practicing physicians.

Our current SOAP note originates from the problem-oriented medical record (POMR) and was developed by Lawrence Weed, MD for doctors—the only ones allowed to write in medical records back in the day. Weed’s hope was that the POMR would end chaotic, non-cumulative episodic and illegible medical charting—and lead to a new and exciting era in medicine—in which (fingers crossed) we could all work together. Imagine that!

Pros & Cons of Problem-Oriented Medical Record
Here are some of the advantages and disadvantage of moving into the electronic age with a uniform medical record system according to physicians interviewed in the anthropological study.

Systematic organization of medical data with problem-orientation rather than disease-orientation
Easily-accessed and complete problem list (that includes psychosocial)
Medical education reform—logical thinking vs. “tyranny of memorization”
More patient-centered & transparent
Uniform communication for teamwork (social workers, RNs can add to record)
Encourages honesty, continuity, and may weed out incompetence
SOAP acronym easy to remember

Forced segregation into patient problems fragments vs. whole-person narrative
Territorial loss of control by encroachment on doctor’s notes/orders
Leads to an “explosion of paperwork”
Reveals ambiguity in patient care
False sense security in titles of problems
Over-medicalization of life

Strong physician supporters trusted this charismatic leader, Lawrence Weed, MD, and his new model of organizing medical records—yet many doctors resisted. Surgeons were most resistant, the internists were ambivalent, psychiatrists demonstrated “damp enthusiasm,” according to the anthropologist.

Culture of Distrust
Most fascinating to me was the obvious culture of distrust in medicine generated by physicians themselves. Doctors back in the day displayed distrust of hospital administrators, nurses, medical students—and even each other! A few quotes from his thesis related to distrust of these four groups—bureaucrats, nurses, medical students, and physicians:

Physician-Bureaucrat Distrust
Ongoing tension between the entrepreneurial and autonomous physician and the bureaucrats has been present throughout modern medical history. Computerized medical records were welcomed by bureaucrats for the “systematizing, auditing, controlling potential” of doctors.

“One of the most common phrases that was used by resistant physi­cians was ‘the POMR is a conspiracy.’ When questioned further they indicated that it was a conspiracy by those in administration to function as administrators want them to: ‘pushing piles of paper around.’ It was also a conspiracy to ‘get the doctor.’ If the game was to get the doctor, then some requirement that everything must be documented would surely be a useful ploy.” (page 269)

Physician-Nurse Distrust
There was “polarization between doctors and nurses who could now question the logic behind a physician’s therapeutic plans on the computer so the ‘computer was voted out of the ward by a closed meeting of the senior medical staff” because it was “territorially unacceptable to those in power.” (page 80)

The “nurses’ SOAPed progress notes were renounced as “ungrammatical gib­berish.” Physicians complained of “non-physicians ‘overstepping their responsibilities’ and were concerned about “who was in control of patient care, exemplified by satirical remarks on ‘nursing diagnosis’” The physicians in both the medical and surgical services spoke of the doctor-patient relationship as being “corrupted by nursing arrogance.” (page 250)

“Within days of the initial physi­cian’s outcry, humorously characterized as ‘who’s writing in my notes?,’ several other physicians used the same ploy to denigrate the nurses.” (page 253)

Physician-Medical Student Distrust
Higher education is about learning and asking questions, yet I’ve found the medical hierarchy methodically oppresses medical students who may be discouraged from thinking independently or questioning their superiors. Some for the first time in their lives fear asking questions during medical training. Our trusted anthropologist writes:

“Within the U.S. medical culture, age, and concomitant status cate­gories (medical student, extern, intern, resident, etc.), usually con­fer greater authority and greater power. As a medical student, the opportunity to affect peer and faculty behavior is minimal, and the well-documented passage from humanist to cynic occurs. Medical students are low in the professional hierarchy, and behave accordingly. For example, rarely do medical students display disagree­ment and displeasure to their medical school clinical faculty. As student physicians increase in age, credibility, and credentials they gain the right to assert their opinion. Innovativeness is not custom­arily rewarded medical student behavior. Only with the acquisition of clinical experience can the opportunity to innovate occur.” (page 145)

Physician-Physician Distrust
The anthropologist found that frequently physicians use “alienating humor” to converse with one another explaining that “much of the humor was at the expense of patients, at other specific physicians or services, at psychiatry or medicine in the surgical domain and vice versa, or commonly placed one physician in a subordinate position. (page 122)

“Internists rarely requested psych consults and had ‘disparaging remarks about the entire psychology and psychiatric services.’” (page 120)

“In medicine, the surgeons claimed that ‘heroic actions are rare in the medical service.’ The surgeons claimed that chronic care is the ‘ballpark of the internist.’ The internists criticized the surgeons as ‘one night stands’; ‘going in and cutting as spectacularly as possibly while we have to do the painstaking clean-up work.’ The ideological differences between internists and surgeons are well known. They begin in medical school, and are strongly reinforced in informal contacts between surgical and medical residents.” (page 253)

“Internists commonly described surgeons as ‘technicians’ and as ‘heroic princes.’ Surgeons referred to internists as ‘boy scouts’ and ‘pill pushers.’ I regret that I did not keep a systematic record of the insulting metaphors that were used by each department; the underlying feeling of division and competition was pervasive in the institution.” (page 141)

After reading the anthropologic study, most shocking to me was the resistance of physicians to befriend one another and how doctors actively attempted to “suppress physician friendships.”

“Many physicians had doubts about the strength, intimacy, and candor of their friendships. Often they mentioned that they worried whether non-physicians were friendly because of the security the physician offered those friends when they were in medical need. Some of the physicians, notably those in the surgical service, were quick to point out that they deliberately made every effort not to build intimate friendships with other physicians.” (page 121)

Of course the “attitude of the hospital’s administrative leaders were totally non-conducive to friendship formation.” complained physicians. (page 122)

So my question today is how is it even possible to create a uniform medical record system with so much animosity and distrust?

Physician Resistance To Innovation—A Paradox
I believe the origin of physician resistance to innovation is threefold: 1) Fear of change (universal among most people), 2) Territoriality and 3) Culture of distrust.

Our anthropologist points out “ . . . the medical record has traditionally been called the doctor’s record, and progress notes were labeled as doctor’s progress notes. If the record is to be considered the patient’s record and notes labeled as progress notes (with team partici­pation), two areas of resistance can already be identified.” (page 261)

Medicine is conceived as “a discipline receptive to change—constantly and carefully evalu­ating innovations for better ways to help the patient. Paradoxically, any changes on the traditional doctor-patient relationship, on fee-for-service transactions, on review of medical care by non-physicians (or by peers), and on the demystification of medical terminology are fought vigorously.” (page 267)

On the one hand, the media reinforces “the desired self-image of dynamic medical and research progress” while “higher education is notoriously conservative and resistant to change”—especially in medicine. (page 268)

So that’s the backstory to electronic medical records. Now let’s look forward . . .

Why Medical Records?
The original purpose of a medical record was to simply record the patient encounter. The therapeutic relationship that flourished organically over time. Appointments were face-to-face with eye contact (no staring at a computer screen) and real conversation that allowed the doctor to get to know the patient’s philosophy, desires, culture, and address their medical needs in the context of their real life. Physicians back in the day could do that with no staff as a solo docs in a simple one-room neighborhood office—often right inside their homes. The record could be one sentence on one index card. Before hospitals dominated the medical scene, all records were primary-care outpatient-based and involved two people—doctor and patient.

Now the modern medical record has been overrun by so much complexity and competing interests that the doctor and the patient risk losing the very foundation of their sacred and healing relationship. The medical record system is a multi-page/multi-window experience that is often neither intuitive nor ideal for any specialty. Tertiary-care hospital-based record systems amass so much information from so many sources that sometimes what you are looking for can’t be found. So the SOAP note has turned into the APSO note so we can locate the assessment and plan amid all the crap entered by medical staff. Except maybe housekeeping, everyone seems to have the ability to add to this ever-more-complex medical record.

Medical records are now not so much used for the patient encounter but to document things done to the patient in ever-shorter visits with unreasonably lengthy documentation required for billing and coding in case of auditing or lawsuits. Of course, the sheer volume of material required for documentation requires more face-to-screen time with the computer than face-to-face time with the patient—and sadly encourages dishonesty and outright lying in the official record with boxes checked for questions never asked and entire sections cut and pasted over and over again on a bloated record based on distrust.

Doctors distrust patients who may sue them so the medical record expands due to CYA medicine and excess labs, tests (and additional documentation) increasing medical expense. Patients distrust doctors and don’t share what’s really on their minds (how can they in 7-minute visits?). Many patients have written me seeking help because their doctor profiled them in the medical record as a “drug addict” or a “bad mom” or “noncompliant” and they can’t get that phrase off their records. Even if they change doctors they feel labeled and experience discrimination. Let’s not forget these medical records are stored in the cloud and on systems that can crash and be hacked in a moment with all patient records and physician NPIs and social security numbers leaked to the world.

So if the truth of a patients life is no longer captured by a medical record due to distrust and bureaucratic bloat, what next? Meet some doctors who have actually fallen in love with their medical records

Welcome Your Ideal Medical Record!
You can actually create an ideal medical record! I did nearly 15 years ago. Back in 2004, fed up with assembly-line big-box medicine, I launched an ideal medical clinic designed by my community. And I created my ideal electronic medical record! I originally intended to buy a real EMR, but while searching for a system, I started my own electronic records on my apple laptop and turns out the system I created with primitive text edit files (now on password-protected Pages files) was better than anything that I could buy! I accidentally created my own ideal medical record and have been practicing happily ever after since 2005 having spent nothing on an EMR! My IT buddy claims that my electronic record may be one of the most secure in the country! How ’bout that?

Since 2005, I’ve helped hundreds of doctors launch ideal medical clinics—and find or create ideal medical records that work for them. One part of the ideal medical clinic experience is to enjoy—even fall in love with—an ideal medical record. So I encourage all doctors out there who are struggling and fighting with a medical record system you don’t like to STOP—and do it differently. Rather than continue weird workarounds to be more efficient and play better with a flawed medical record system, I’m encouraging you as an independent, entrepreneurial physician to create YOUR ideal medical record—even if just a weekend science experiment. You can even go back to paper or index cards if you want! You are the boss. Do what’s ideal for you and your patients.

Four Impediments to Ideal Medical Records
1) Third-party intrusion that treats doctors as economic units and patients as widgets. 2) Competition among health systems that won’t do what’s in the best interest of the patient. 3) Infighting among doctors. Academic vs. community, tertiary vs. primary care, MD/DO vs NP/PA vs. ND so is it really possible to have a system that works for everyone? 4) Patient distrust. Ask yourself if your current medical record system allows complete trust and transparency in your relationship with your patient? Is your medical record in any way impeding the ability of your patient to disclose the full truth of their life experience? If so, you must change!!

Here’s how a great idea can turn into a shitshow. I asked several doctors, “What’s the most ridiculous thing you ever had to do on EMR?” 1) One hospital required progress notes to be dictated (could not be typed) into their horrific EMR. Notes would take several days to post, so most consultants (and even the primary team) had no idea what was going on with the patients. 2) Our EMR is a black screen with green print. 3) When I was working as an emergency physician, they switched EMRs. I was then told I had 1700 charts to complete which I had already done in the previous EMR. I refused to do this. They called security to escort me off the premises. 4) To dictate, have to use internet explorer. To prescribe have to use Firefox. So, to do one note have to use two browsers at a time. Frequently when saving what has been typed, I get a spinning wheel and then receive a message that there is an error and everything done is lost. 5) An gynecologist lamented a standard template that noted “gravid uterus” on every normal exam. She had to edit it to a default normal on every single note. 6) Family doc says: “Spent months doing stage 1 MU, correcting problems for EMR company. Finally switched to different EMR after much frustration then got audit from Medicare looking for MU screenshots from Old EMR which could not be done on read-only status. Wrote a letter of explanation and was told to pay back MU ‘bonus’ of $36K on top of the $75K we spent on IT support and staff time to be able to attest. Total loss over $100K not counting a year of my time away from my kids.” 7) Surgeon asks, “Isn’t the primary purpose of EMRs For the government to more easily track Medicare fraud?”

5 Ways Distrust Undermines Medical Records
As a patient, have you ever wanted a doctor to keep some things you share off the official medical record? Why? In one word—discrimination. Fear of discrimination makes comprehensive medical records a joke.

1) Pre-Existing-Condition Discrimination. “My entire GI tract was excluded based on one episode of stomach pain treated with antacids,” a friend reports. “Exclusions can go on for years. The Affordable Care Act greatly improved this, but if that were overturned?” he asks. Patients frequently request to use fake names or exclude diagnoses from chart. Genetic tests (like 23 and me) are done under assumed names (otherwise a gold mine for insurance companies to jack up rates). Doctors are often careful not to label a patient with a working diagnosis to prevent insurance company discrimination.

2) Drug-Use Discrimination. Due to federal government’s inclusion of marijuan as an illegal schedule 1 narcotic, even suggesting CBD oil can be seen as violation of regulations. In NY doctors say they cannot counsel patient to use cannabis products or any other schedule 1 under DEA regs or it’s a violation of their DEA license. Of course, any number of illicit and legal drugs are kept off the official record for a variety of reasons—including mental-health discrimination (see #4).

3) Sexual-Orientation Discrimination. Lesbian, sex worker, polyamorous relationships not declared to doctors leading to obvious difficulty is screening/risk reduction conversations and exams.

4) Mental-Health Discrimination. Physician mental health is a huge taboo for doctors. One physician writes:

“I’ve seen good friends denied disability and life insurance policies tiered to same as 1 pack per day smokers because of history of depression (even well controlled with meds). Coercive and unnecessary referrals to Physician Health Programs. Sometimes boards take away the physician’s freedom, dignity, even license. Agencies and some medical boards don’t differentiate between illness and impairment. They apply policies of the American Disability Act and HIPPA differently to physicians in the name of ‘protecting public safety,’ licensing agencies, corporate medicine authorities, and many other powerful bodies can mandate release of such information without even the slightest sign or evidence of impairment. One recent example is our physician ER colleague who had to fight 10 years for her license due to disclosing feeling the Baby Blues at work. discrimination SHOULD NOT and DOES NOT only apply to a few listed categories of race, gender. Discrimination due to one’s profession is also a type of discrimination that is not addressed enough when it comes to physicians’ rights.”

Veteranss/firefighters/paramedics mental health is also an issue as it related to discrimination based on employment. The fear of denied benefits based on PTSD. Many will only talk off the record and away from prying eyes and ears…no paper, no pens, no electronic devices. Some have suddeny been fired after PTSD evaluations.

5) Legal-System Discrimination. Release of medical records to attorneys can cause huge problems so patients avoid disclosing their most intimate traumas. Workers compensation attorneys deny claims based on previous alcohol or drug use or experimentation. Medical records are a common point of attack in divorce, criminal, civil and child custody proceedings. A slip-and-fall case can lead to big disclosures in court displayed right on the big screen in front of 12 peers and anyone else in attendance (these court cases are public, by the way)


“Our EMR’s are overly inclusive with way too much personal information on the summary sheet,” reports one doctor, “which can be viewed not only by other doctors but their nurses and nursing assistants and any one else who has to open your chart to take vital signs or document history. That’s a lot of eyes on your personal info. Curious staff can scroll through the whole thing right in front of you and make faces without realizing it and people talk.”

“My doctors at a clinic put my dependence on government housing in their summary of my medical history when referring me to another doctor,” says one patient. Another woman says, “I always laugh when I read privacy policies, knowing that they are lots of exceptions.”

Discrimination EMR Workaround -> Fake Names/Fake Charts
Doctor reports, “Our local hospitals routinely use fake names for VIPS and I have been asked to use a fake name to protect the patient from being shut out of life and disability insurance plans.” I personally know of
medical students admitted under fake names for psych admits. How destabilizing is that for someone who is already having delusions? A psychiatrist reports placing “high-profile athletes” on fake charts with fake names and even keeping those charts with her and not left with other charts in clinic or on EMR when working corporate medical jobs. Patients request the use of fake names to order meds to avoid problems getting life insurance.

My Challenge to YOU—those of you no longer willing to submit to a system that is failing . . .

We are undergoing a transition in health care from centralization to decentralization, from tertiary care back to more primary care, from production-driven to relationship-driven care. Doctors and patients are not well served by big-box assembly-line medicine—it’s dangerous and unsustainable emotionally, spiritually, even financially. There is no way in the world you can deliver the kind of care that you dreamed of delivering to your patients in 7-minute increments while documenting on a computer system for twice as long as your face-to-face visit. I’m encouraging you all to think way out of the big-box. Your life is too big for your little cubicle. Your patients need the real you and your expertise. What medical record would allow you to create the ideal encounter in your ideal clinic with your ideal patients and help them heal?

I’m spending the next two weeks helping physicians create their most out-of-the-box ideal medical record for themselves that makes every patient encounter pure joy. I will report back our success!

My 3 Challenges For YOU. Ask yourself . . .

1) Should your ideal medical record be specialty specific? If you could create a specialty-specific medical record for your ideal clinic what would it look like? For your flow? For ideal patient encounters?
If you’ve ever felt that EMRs were created by people who according to one doc, “no fucking clue what your job is,” then why not create your own? If you don’t want to talk about blood pressures and arrhythmias and how many bags of NS given, and want to talk about mood, thought process and content, hallucinations, delusions, and suicidal thoughts, then go for it! What what would that medical record look like?

2) Is there a section/question you wish were in the medical record that is not? Maybe in contrast to the problem list, you prefer personal strengths and triumphs or a timeline of life events. Do you care about hobbies? Want to know what patients do for restoration and joy?  Don’t want to limit social history to just tobacco and alcohol? You want details on relationships and abuse history, occupational and recreational exposures risk? Want a spiritual section or a diet history? Go for it!

3) Do you want to try paper charts? Lots of ideal docs in ideal clinics LOVE their paper charts!!! I really had no idea how many doctors I truly admire that are loving their paper charts in successful practices—and some still accept insurance! Create an ideal paper chart as a fun weekend science experiment.

In summary, we have a failed medical record system and slapping BandAids on something that is not working to try to make it work is not the answer. Maybe one of you innovators will come up with a med record that can be used by many more docs to bring them joy too! WE ALL NEED YOUR INNOVATION!

Now go have FUN! Then definitely share your successes! If you doubt that this can really be done, listen to these doctors who are living their dreams!

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