Not “burnout,” not moral injury—human rights violations →

Burnout is a slang word for end-stage drug addiction first used on the streets of inner city America in the early 1970s. During that time, psychologist Herbert Freudenberger volunteered at a New York City free clinic treating addiction. He overheard the term and used it to describe himself and clinic staff in a 1974 article on staff burnout detailing long-term physical and psychological job stress.

He then authored a book on burnout in overachievers and another on burnout in women further popularizing the slang word which seeped into common lexicon. Burnout was no longer limited to Americans overdosing in back alleys. Now housewives and high achievers and anyone stressed at work suffered from burnout too.

“Physician burnout” first appears on my PubMed literature review in American Medical News in July, 1981. It is unclear to me who first applied the term to doctors. What is clear to me—is that despite medicine’s obsession with burnout for nearly four decades—the epidemic of physician cynicism, exhaustion, and despair is worsening.

So why are physicians experiencing physical and mental collapse from overwork? Psychiatrists define burnout as a job-related dysphoria in an individual without major psychopathy—meaning you’re normal; your job is killing you.

Meanwhile physician burnout books and breathing exercises are offered by burnout coaches on every corner. Curious why physician burnout is on the rise amid the plethora of burnout programs, I asked a physician burnout coach, “Don’t you think all your ‘burnout’ breathing exercises and EMR workarounds just prolong the agony for physicians in toxic working conditions?”

He replied, “Yes.”

Since that 2015 conversation, I’ve been debunking burnout as a victim-blaming buzzword that prolongs physician agony by avoiding the real issue leading to physician despair. So what’s the real issue? Enter Drs. Wendy Dean and Simon Talbot with their landmark 2018 article, Physicians aren’t ‘burning out.’ They’re suffering from moral injury. In it they explain:

The concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. . . Physicians are the canaries in the health care coal mine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system. . .The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto [physicians] by switching them to team-based care; creating flexible schedules and float pools for [physician] emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training.

Yes. Thank you. Exactly.

Last week the anti-burnout buzz accelerated when ZDogg quoted my 2015 blog—Burnout is BS—in his viral video “It’s not burnout, it’s moral injury” echoing my advice that we stop saying the victim-blaming term.

Now we’re getting somewhere. But is it really moral injury?

Moral Injury is a term applied to combat veterans in 1998 by psychiatrist Dr. Jonathan Shay. Moral injury is damage to one’s conscience when perpetuating, witnessing, or failing to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct (often resulting in profound shame). Moral injury is a normal human response to an abnormal traumatic event—a deep soul wound shattering one’s identity and morality. Dr. Shay’s original definition was based upon his patients’ war narratives and Homer’s Iliad (762 B.C.) and required three components: (i) betrayal of what’s right by (ii) someone who holds legitimate authority in a (iii) high-stakes situation. Individuals with moral injury may see themselves and the world as immoral and irreparable.

Moral injury now extends beyond combat veterans to include physicians in 2018 when Dean and Talbot announced their opposition and alternative to the label physician “burnout.” They believe (as I do) that physician cynicism, exhaustion, and decreased productivity are symptoms of a broken system. Economic forces, technological demands, and widespread intergenerational physician mental health wounds have culminated in a highly dysfunctional and toxic health care system in which we find ourselves in daily forced betrayal of our deepest values.

Manifestations of moral injury in victims include self-harm, poor self-care, substance abuse, recklessness, self-defeating behaviors, hopelessness, self-loathing, and decreased empathy. I’ve witnessed all far too frequently among physicians.

Yet moral injury is not an official diagnosis. No specific solutions are offered at medical institutions to combat physician moral injury though moral injury treatment among military may include listening circles (where veterans share battlefield stories), forgiveness rituals, and individual therapy. The fact is most victims of moral injury struggle on their own.

With no evidence-based treatments for physician moral injury and zero progress after forty years of burnout prevention, what next? Enter the real diagnosis—human rights violations—with clear evidence-based solutions.

Human rights is a term coined by Eleanor Roosevelt in 1947 when she suggested ‘rights of man’ be changed to ‘human rights’ leading up to the 1948 Universal Declaration of Human Rights adopted by the UN General Assembly as a standard for all people in the world. Physicians are strong human rights advocates—even activists in disaster zones, yet we have failed to protect the human rights of our own trainees and doctors. In 2014, I began reporting human rights violations in medicine after uncovering widespread abuse in medical training and practice via my physician suicide helpline. Since 2012, I’ve spoken to thousands of suicidal doctors—even published a book of physician suicide letters. Doctors have the highest suicide rate of any profession. Why?

Not burnout. Not moral injury—human rights violations—and those who survive the abuse often suffer lifelong sequelae from the trauma.

Physician work hours are far out of compliance with labor laws deemed safe in other industries. Companies in Japan face criminal sanctions for suicides (and non-suicide deaths) if employees work more than 60 hours/week, yet our doctors work 80, 100, even 120-hour weeks (trainees are forced to lie on work logs to comply with the “80-hour cap”). Extreme sleep deprivation leads to hallucinations, life-threatening seizures, and post-shift fatal car accidents (plus medical errors). Human rights abuse includes sexual harassment, racism, food/water deprivation, hazing, bullying, pimping, even physical assault—trainees have been hit with knives, punched, and left crying in operating rooms and hospital hallways.

The solution for labor law violations is compliance, for sleep deprivation is a bed and pillow, for food/water deprivation is regular meals, and I’m sure we all agree there’s no place for discrimination and violence inside our hospitals. Understaffing cannot be solved by continuing to force new residents to work beyond their physiologic capacity for minimum wage.

Naturally medical institutions would rather celebrate their new chief wellness officer and meditation garden than take responsibility for these human rights violations against their own physicians and trainees. Denial and avoidance only perpetuate abuse leading to more suicides.

I’m a systems thinker, a scientist, a doctor. My job is to prevent human suffering and death—even when inflicted by institutional violence against physicians inside our own hospitals.

In medicine, combating illness requires primary, secondary, and tertiary prevention. Primary prevention intervenes before injury (seatbelts). Secondary prevention reduces impact of established illness (antidepressants). Tertiary prevention improves quality of life in those with chronic illness (PTSD support groups).

Primary prevention to prevent human rights violations against physicians includes unionizing, class action lawsuits, wrongful death litigation, strikes, walkouts, boycotts, peer leader negotiation with administrations, hospital fines, and loss of accreditation. Secondary prevention includes psychiatric care, counseling, modified/part-time work schedules, leaving toxic employers, and launching your own practice. Tertiary strategies are whistleblowing by speaking up and writing articles detailing abuse, support groups, retreats, and self-care.

Solving our crisis requires a definitive diagnosis and treatment plan. Now is the time for brutal truth—and action.

Moral injury may be less abrasive and more academically and politically acceptable than human rights violations. Should we choose a diagnosis based on what’s socially acceptable?

Imagine if we say “heart injury” rather than myocardial infarction or ruptured aorta. If we don’t name the definitive diagnosis, how do we progress to appropriate labs, tests, and interventions? If we fear the truth and waver on the assessment, patients will die from our indecisiveness.

Let’s not waver on the truth.

We’re in the midst of a medical system emergency that can’t be solved on an individual level with tertiary prevention strategies. Emergencies require immediate action—airway, breathing, and circulation, not yoga and Zen meditation.

Here’s a quick 2-minute cartoon recap with transcript.

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Living your spiritual calling in medicine →

Inspiring presentation to students at The University of the Incarnate Word School of Osteopathic Medicine that received a standing ovation. Listen in below to full three-hour event (including Q/A) and/or transcribed presentation below:

Each year our future physicians enter medical school with their mental health on par with or better than their peers. The best and brightest humanitarians with a deep desire to help and heal others soon find themselves in a career with the highest suicide rate of any profession. How did medicine lose its way? How can we inspire students amid a culture that undermines their own mental health? Breaking through a century of medicine’s mental health stigma, Dr. Wible demonstrates how to be true to your original calling, and why being congruent with your deepest spiritual values turns medicine from a job into the most fulfilling career on the planet. (Plus loving your life as a doctor just might be the antidote to our physician suicide crisis)

Mark Clark, PhD:  With physicians stories certain things kind of stick out to me. Particularly on the lookout for things that I think are possibilities of looking beyond somebody as simply a role model and a mentor. First thing that struck me early on in Dr. Wible’s biography was the fact that she’s a family physician and she started out around the time I was starting to get into medical humanity so early 2000, somewhere in there. She got frustrated in the struggle with all the weight of family practice—the direction her profession was going. So what she did was go off into the community, lead a town hall meeting and she asked what kind of clinic they wanted. And from there she got started developing a solo community clinic.

This is not exactly the subject of her talk today, but I thought it was important because what I see happening is this finding yourself in the condition of helplessness or vulnerability—but responding to that in action. So she had the town hall and she got going. When we talk about “burnout” we feel a true lack of agency. So what I want you guys to look at in mentors, in role models, in physicians is where especially they find a way to act—despite whatever circumstances they’re in—there is this agency and this capacity to act. That can really make a difference.

So she may talk about that. It really struck me as part of who she is and something that was worth noting. So she’s very active still in her family medicine clinic. Because of her own life experience, she’s gotten involved with physician suicide prevention. She’s investigated more than 1,100 doctor suicides and her extensive database and suicide registry reveals high-risk specialties—and solutions. In between treating her own patients Dr. Wible runs a free suicide hotline and has helped countless medical students and physicians heal from anxiety, depression, PTSD and suicidal thoughts so they can enjoy practicing medicine again.

I had several delightful conversations with Dr. Wible leading up to this event and I just felt like we are on the same wavelength. I was just incredibly happy when she presented me with the title of her talk which I thought was completely in line with what we have going on in unit nine and all the way through these last two years. Healing our healers—living your spiritual calling in medicine. Welcome Dr. Wible.

Pamela Wible, MD: Thank you so much for having me. I’m very, very excited to be here. Thank you for getting up early for me. So yeah, did you know that I almost went to med school in San Antonio? I only interviewed at two places. Back in the day when you could get into residency with only two residency applications. I got my top choice of residency and med school—and I only applied seriously to two med schools as well. But there was a cool thing with Texas, I don’t know if they still do it, where you apply with one application that goes to all schools. That was awesome. So yeah, I ended up at Galveston.

In my San Antonio interview, this old-guard med school guy was like really scary. He tried to scare us or something and I just thought, “Oh I love San Antonio but that was scary.” I’ve got to go somewhere where it’s safe. So I went to Galveston and I had my own issues there. But I’m glad that I went to UTMB, and my mom went to UTMB as well. So we just went back a few years ago to her 50th medical school reunion and it was my 22nd and there’s not many mother—daughter pairs that can go back to their medical school reunions together so that was pretty cool. Plants the seed for you all. Have your children come here I guess 25 years from now—and you can enjoy reunion together too!

So I thought we would do this in a really interactive and fun way where we could all learn together. Hopefully you all have index cards because I have a little experience for you all. I’m going to ask three questions. So on your index cards if you could just put one, two, three, one on top of the other. First question (don’t think too hard, just sort of stream of consciousness) is how old were you when you very first had the idea that you were born to be a healer or a doctor on this planet? The very first time you thought this could be your destiny. If you are on faculty, please answer these questions as well. You might want to make a note on your card that you are faculty. I would love to collect these at the end and just sort of see what everyone has written down. It would help me understand where medical students are today versus my experience 25 years ago.

So that’s the first question. Number two—what was your primary motivation back at that age when you first had that idea? What was your primary motivation in one or two words? Why is it that you wanted to pursue this profession?

And then number three. Same age. Take yourself back to that moment. What was your big dream that you had? Your original dream when you were four or five, eight years old—that original dream that you had to cure cancer, you wanted to be an amazing pediatric oncologist. Whatever it was that you thought that you were going to be at that moment. Maybe just a pediatrician in a small town or a family doctor. Write that down as well.

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Physician “burnout”—a coverup for human rights violations in medicine →

Since 2015, I’ve advised doctors to stop using the word “burnout.” Here’s why.

Each year our best and brightest, most compassionate students enter medicine—a career with the highest suicide rate of any profession. Each year more than 1 million Americans lose their doctors to suicide. Jumping from hospital rooftops. Found hanging in hospital chapels.

Classic response? Blame the victim, then cover up the suicide with medicine’s favorite victim-blaming buzzword—burnout—a slang word from the 1970s for end-stage drug addiction—now weirdly applied to doctors! Here’s how it works . . .

Physician “burnout” blames the victim NOT the medical system that actually kills doctors—and patients! Plus it’s a cash cow for physician predators and profiteers—all the burnout coaches cannibalizing the corpses of their colleagues—divided and conquered by bullying, hazing, and sleep deprivation—the foundation of medical training that forces new med school grads to legally work 28-hour shifts treating heart attacks, gunshot victims, and delivering stillborns—with no debriefing for their trauma. No bathroom breaks. No time to eat, surgeons collapse from dehydration and hypoglycemia. Here’s a doc found sleeping on an elderly comatose woman while starting her IV. (All true stories) An ICU doc forced to keep working during a seizure. Another doctor working while miscarrying her baby.

These human rights violations lead to suicide (and families destroyed by suicide) plus lifelong physician PTSD, anxiety, depression, divorce, strokes and heart attacks—when our doctors are forced to work 80, 100, even 120 hours per week—that’s two to three full-time jobs! Criminal in Japan where companies are held liable for suicides when employees work just 60 hours per week.

Now doctors are standing up against the abuse. So hospitals are retaliating with FORCED WELLNESS on the overworked. With mandatory 6 am sleep deficiency lectures (after 24-hour shifts!) and mandatory resilience training for military doctors with crayons and adult coloring books.

FYI: Appointing Chief Wellness Officers while perpetrating abuse is like putting a Band-Aid on a ruptured aorta. Enough burnout bullshit guys. Claim responsibility for human rights violations at your medical institution. Stop abusing your staff. Then apologize to victims (and their families). If you’re being abused, please leave your abuser (who may in fact be your burnout coach keeping you caged in your cubicle).

How to stop human rights violations in medicine

Human rights are universal moral principles that apply to the treatment of all human beings no matter sex, ethnicity, religion, culture—or profession. These are basic freedoms and standards of human behavior protected by law—both internationally and nationally—from birth until death.  Sadly, these laws often do not protect medical students or doctors.

Recognize human rights violations in your medical institution and speak up against unsafe and inhuman work hours (> 60 hours/week), sexual harassment, bullying, food/water deprivation, sleep deprivation, hazing, racism, censorship and lack of freedom of speech, intimidation, and prohibition of peaceful assembly after a physician suicide (to name a few).

Since 2012, I’ve been running a physician suicide helpline and have spoken to thousands of physicians suffering from occupationally-induced anxiety, depression, PTSD, and suicidal thoughts as a result of chronic human rights violations—and lack of access to mental health support in a profession that involves constant exposure to suffering and death.

What physicians need now

Protection by labor laws standard in other industries including mandatory meal and bathroom breaks

Protection by the Americans with Disabilities Act including immediate removal of invasive mental health questions on applications for state licensure, hospital privileges, and insurance credentialing.

Access to non-punitive mental health care to prevent occupationally induced lifelong mental health sequelae from chronic exposure to death and suffering.

Protection under the Unites States Constitution that guarantees freedom of speech and a right to peacefully assemble—especially in the aftermath of a physician suicide.

Archived articles on human rights violations in medicine

More on the fallacy of physician “burnout”

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Medicine’s willful blindness to overworked doctors →

BBC World Service Business Daily Report on overworked doctors

Dr. Yumiko Kadota: There was one day where I worked for about 20 hours, and the next day I was absolutely exhausted and I wanted to have a quick break and then return back to the operating theater. I wasn’t allowed to, the consultant said to me, “Oh, I remember working those hours as a registrar. It’s good for you.”

Vivienne Nunis: Exhaustion, depression, even thoughts of suicide, in today’s business daily with me Vivienne Nunis, I’m exploring the work pressures pushing some doctors to breaking point.

Dr. Pamela Wible: I saw medicine in its heyday, and I knew what a real doctor was, and that’s what I wanted to do. I wanted to do house calls and be the womb-to-tomb physician that you and your family members could trust for a lifetime. I actually became suicidal to the point where I did not get out of bed for six weeks, and I was just praying for my own death.

Vivienne Nunis: Medicine has long been looked upon as a respectable career. We trust doctors with our lives, and in return, we expect certain standards of care, but what if those doctors were under so much pressure and working such long hours their jobs became impossible, and yet they felt unable to speak out. Today we’re looking at the hidden problems in medicine, and asking what to do in any job where a culture of silence prevents bad practice from being exposed.

Margaret Heffernan: They’ve absorbed the hierarchy of the medical system, and they know that advancement depends on pleasing their seniors, which equals—don’t rock the boat.

Vivienne Nunis: Business Daily from the BBC.

Dr. Yumiko Kadota: I wanted to do plastic surgery since I was in high school, because I’d heard about a man who had had severe trauma to his jaw, and the reconstructive surgeons used a part of his rib to reconstruct it. I thought, “That’s something that I’d love to do, because it’s so creative.”

Vivienne Nunis: Thirty-one-year-old, Yumiko Kadota, spent six years in Sydney Medical School. After graduating as a junior doctor, she developed a passion for plastic surgery. By 2018, she was eight years into her medical career, working as a registrar, and hoping to be selected for the extremely competitive final five-year training course that would mean that she could work as an accredited plastic surgeon in Australia. But the pressures involved in pursuing that dream, left Yumiko traumatized.

Dr. Yumiko Kadota: So I would be doing mainly hand surgery at this hospital, as well as trauma to the face and elective skin cancer surgeries. The greatest demand was being on-call for 10 days out of every fortnight, and sometimes calls were coming in the middle of the night, and when I did get a phone call about a sick patient or any patient that a doctor or a nurse at the hospital was concerned about, I would get called back into the hospital.

Vivienne Nunis: So what kind of hours were you spending at the hospital by this stage?

Dr. Yumiko Kadota: So the contact hours were about 70 hours a week, and then on top of that I was on-call. So the typical fortnight was that I would be on-call for 180 continuous hours, and then I would get one night off, and then do another 80 hours on-call, and then I would get the weekend off, and then the two-week cycle would start again.

Vivienne Nunis: And how did that affect you?

Dr. Yumiko Kadota: Being on-call for 10 days means that there is a lot of mental unrest, and then eventually I started to notice a deterioration in my physical health.

Vivienne Nunis: And at this stage, you were spending a lot of time at the hospital, not just when you were working, but between shifts because there was just no point in going home.

Dr. Yumiko Kadota: If I would finish operating at three o’clock in the morning, I wasn’t going to drive home for an hour, sleep for an hour, and then drive back again, so I just ended up sleeping in a chair or a spare hospital bed whatever I could find. And there was one day where I worked for about 20 hours, and the next day I was absolutely exhausted and I wanted to have a quick break and then return back to the operating theater, but I wasn’t allowed to, the consultant said to me, “Oh, I remember working those hours as a registrar, it’s good for you.”

Vivienne Nunis: Yumiko raised her concerns with the hospital, pointing out that she’d worked 100 hours of overtime in one month. She suggested changes to the staff schedule that would have spread the workload more fairly, but senior consultants resisted the changes. At the end of last year, Yumiko wrote a blog post detailing her experience as a trainee surgeon in Sydney, the response was overwhelming. Medical students and health professionals from as far away as the UK, Poland, the US and Columbia contacted her to share similar tales of extreme pressure and overwork.

Dr. Yumiko Kadota: Though I realized that I had to remove myself from the situation if I wanted things to get better.

Vivienne Nunis: Did you feel at any stage that your own state of fatigue was putting your patients at risk?

Dr. Yumiko Kadota: Absolutely. I explicitly said, “I am concerned about my level of fatigue to the point where it might start affecting the care that I give to my patient.” You know, we’re not machines, we’re humans, and so anyone under that kind of duress could easily make a mistake.

Vivienne Nunis: You took the decision to resign.That must have been very hard?

Dr. Yumiko Kadota: It was something I dreamed about from when I was in high school, so to let go of your dream is a very difficult thing to do because often we attach our sense of self to our hopes and dreams, and becoming a surgeon was a huge part of my identity, instead of thinking of it as something I did, I thought of it as something that I was.

Vivienne Nunis: So you found yourself in a position where your health was so impaired, you ended up in hospital, but not as a doctor, as a patient.

Dr. Yumiko Kadota: That’s right. Yes it was very strange. Initially when my doctor suggested I go to hospital, I said no. It was because I just wasn’t getting better, it just got worse and worse. I was having problems with my sleep, and I was having flashbacks and traumatic symptoms, so I really was in a terrible place. I think it’s prevalent everywhere, and especially in Australia. The greatest response has been from people in Australia. I think it’s medicine’s dirty little secret. We all know how terribly the unaccredited registrars are treated, but no one really talks about it because these are the registrars who are still waiting for selection onto the advanced training program, so no one would ever say anything about it. We just keep it to ourselves.

Dr. Jason Lamb: I was also pursuing a career in plastic and reconstructive surgery, and frankly found myself just burnt out, and ended up deciding to give up on plastics. I was regularly doing 100 hours a week, and I was on-call for an entire year. I actually ended up being replaced by two and half people for that particular job. My boss said, “I’m not telling you to do these hours, but if you don’t, patients will suffer. But I’m not telling you to do them which really puts you in a really difficult situation.”

Vivienne Nunis: That’s Dr. Jason Lamb. Like Yumiko, he was a junior doctor, hoping to one day become a plastic surgeon. He too was put under enormous stress at a Sydney hospital where he worked.

Dr. Jason Lamb: You’ve got such a desired position and so few of them, and that power is held by a very few people. Yeah, we want to do these hours. We want to impress these consultants so no one will speak out, because if you speak out that’s kind of it for your career.

Dr. Jason Lamb: I remember the consultants sat us down and said, very bluntly that you have three chances to displease me, after that I will call the relevant consultants and make sure you never work in plastics again.

Vivienne Nunis: So how is it that bullying, intimidation, and impossible working hours became part of the deal in some parts of medical practice, and why are such harmful work practices allowed to persist?

Margaret Heffernan: So my name’s Margaret Heffernan. I’ve run five businesses. Ten years ago I started work on a book called Willful Blindness, looking at how it is that organizations make huge, often catastrophic blunders, and afterwards realize that all the information they needed to make a better judgment was right in front of them, but they somehow missed it.

Vivienne Nunis: Margaret has also written two plays about Enron, the US energy giant that collapsed in one of the biggest corporate failures in history, and it’s now a byword for corruption and mismanagement.

Margaret Heffernan: In the trial of the executives at Enron, the judge cited the doctrine of willful blindness, and I remember reading that and thinking, “Ooh, that’s a really interesting idea.” And at the same time, the banks started to collapse, and everybody said they couldn’t have seen it coming, and I thought, “Oh, come on. Lot’s of people saw it coming.” And this idea of willful blindness really stuck.

Vivienne Nunis: So it’s the same culture of staying silent in the face of such obvious bad practice also a problem in medicine.

Margaret Heffernan: If you lose one night’s sleep, which doctors routinely do, it’s the equivalent of being over the alcohol limit. We don’t let people drive like that, but we let them operate on us? In the United States, for example, physician-induced errors is the third leading cause of death. This is a big, real problem, and it’s about fundamentally human limits, which managements, and definitely finance officers and economists choose to ignore.

There is something in medicine known as the hidden curriculum which is, if you ask medical students when they start their training, “If you were asked to do something that wasn’t really appropriate. If you were asked by a consultant, ‘Would you do it?'” Most students will say, “Yes.” By the end of their medical training, more students would say yes. They’ve absorbed the hierarchy of the medical system, and they know that advancement depends on pleasing their seniors, which equals—don’t rock the boat. You also have to factor in to the fact that at the junior level, you often have people who have paid a very large amount of money, or their parents or their whole family may have paid a large amount of money for their training. Their family, especially in a first generation of medics, are unbelievably proud of their children. Taking all that education and throwing it away, it’s just, it’s too distressing for too many people that other people really love.

Vivienne Nunis: And also their sense of self, often this happens in many careers, is wound up so tightly in their profession that that’s also hard to let go of.

Margaret Heffernan: Yeah. And it’s a really good point, and it’s not just a sense of self, but it’s a sense of self as someone whom society regards as respectable, valuable. It’s a big deal to throw that away.

Vivienne Nunis: You’re listening to Business Daily, with me, Vivienne Nunis. Today we’re investigating the extreme pressure some doctors face as they try to build a career. We’ve heard from two doctors in Australia who’ve walked away from their careers in surgery. The next story you’ll hear is from a doctor in Hong Kong. He’s asked to remain anonymous, but he got in touch to explain that doctors there are required to work shifts in public hospitals that last 36 hours.

Hong Kong Doctor: I think everyone knows what you’re getting into as a doctor in Hong Kong. The 36-hour shifts are very well known, not just to doctors but to also to the lay people. There is a TV series called On Call 36 Hours. In Hong Kong the doctors are quite fortunate in that after their first year of internship, they get their full registration and they can go out to private practice. So a lot of people survive for that one year, then leave to private practice.

Vivienne Nunis: Practices like this, forcing new doctors to work so many hours, 36 hours in one shift, is actually driving doctors away into the private system.

Hong Kong Doctor: That’s definitely one of the issues.

Vivienne Nunis: And the problem continues.

Hong Kong Doctor: And the problem continues.

Dr. Pamela Wible: I’m Pamela Wible, a family physician in Eugene, Oregon. I’m also an activist in preventing physician suicide, and the author of Physician Suicide Letters—Answered.

Vivienne Nunis: Dr. Pamela Wible is somebody who knows all too well how common it is for overworked doctors to be pushed to the brink.

Dr. Pamela Wible: I became suicidal myself in 2004. It was 100% occupationally induced. Both my parents are physicians, so as a child, I saw medicine in its heyday, and I knew what a real doctor was, and that’s what I wanted to do. I wanted to do house calls, and be the womb-to-tomb physician that you and your family members could trust for a lifetime. I actually became suicidal to the point where I did not get out of bed for six weeks and I was just praying for my own death. Every night I wanted to die in my sleep peacefully.

Vivienne Nunis: Dr. Wible realized she needed to step away, and she opened her own family practice based on old-fashioned doctor-patient relationships. Years later, as a number of doctors she knew were found to have killed themselves, she realized her own experience was far from unique.

Vivienne Nunis: She started a blog that led to her receiving cries for help from suicidal doctors all over the world.

Dr. Pamela Wible: Yeah, I feel like the suicide rate is accelerating. I would love to have the clear accurate data for this, but because it’s a taboo topic it’s not been tracked properly. So when I began to express myself through speaking, blogging and such, the floodgates just opened. The cascade of emotions flowing towards me from people, from all ends of the world, Pakistan, India, UK. Even in US, like truck drivers, and pilots, and such, if they wanted to, they cannot work more than 60 hours a week, there is a cap. That cap is placed there for safety, for the safety of the person driving the truck, flying the plane, and of course, everyone else on the highways and on the plane. You do not want the person at the helm being sleep deprived, and depressed, and suicidal, without treatment. So why are we allowing this to happen in our intensive care units, when our loved ones are on a ventilator, being treated by somebody who has not had sleep in several days, and is working essentially three full-time jobs?

Vivienne Nunis: So what can be done to prevent harmful work practices becoming the norm?

Dr. Pamela Wible: I mean I think it’s sort of a no-brainer, like we shouldn’t be treating people like this anywhere in the world. But in our hospitals? Not just in the type of care you receive, but the medical mistakes and your likelihood to die or even survive a hospitalization has to do with the mental health of the person who’s caring for you, and they simply are functioning on fumes, if we don’t re-structure our medication education system in a way that’s absolutely humane for everyone.

Vivienne Nunis: Author and expert on institutional blindness, Margaret Heffernan, says other industries have successfully stamped out poor working practices. Are there other industries, I’m thinking about banking perhaps, where this kind of expectation is put on junior members of staff?

Margaret Heffernan: Definitely, banking is one, but I think one that’s really striking because in all of my research, it’s the one that has made the greatest changes, is the aviation industry. Really for the last 30 years, there has been a huge effort to ensure that the industry as one, where the culture is what they think of as a speak-up culture. Anybody who sees anything going wrong, has an obligation—an obligation to speak up about it.

When, due to fatigue, or distraction, or overwork, or whatever, when a plane drops out of the sky, everybody notices that. There is an investigation, and the findings of the investigations are public. When a patient gets bad treatment on the whole it gets glossed over. It’s invisible. There are patients every day who get inferior sub-optimal treatment. When a patient dies, there’s some kind of investigation, but it isn’t a headline case. This isn’t hundreds of people dying, this is someone who was ill who died, and so it becomes kind of invisible in hospitals. It becomes a little bit invisible to the poor people working in these systems, and this is not that they are heartless, brutal people, but when this happens day-after-day, it isn’t exceptional, and so reacting to it as though it were exceptional, seems a kind of over-reaction, and so it becomes normalized, and that’s how it comes to be that people are blind to it.

Certainly sticking together is really important. You know, the doctor who wrote the blog post took a huge risk, and in general, I intend to advise people, if there’s an issue you want to confront, do it as a group, not on your own, because you’re really exposed if you just do it on your own. But I take my hat off to the people who do dare to raise it, because it truly isn’t that people don’t know. They’re getting away with it.

If  you’ve have been a victim of human rights violations in medicine, have been overworked to the point of self-harm or harm to patients, please leave your comment (even anonymous) below, or reach out to Dr. Wible confidentially here.

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Healing our healers—honoring Florida physicians we lost to suicide →

A Florida community heals by celebrating the lives of 3 doctor suicide victims. Friends, family, & colleagues unite to share their love—and prevent future suicides. Listen in above to keynote and lively panel discussion. Full transcript and slides below.

Dr. Pamela Wible: I am so happy to be here. Mostly because I consider it a miracle—an act of God—that I even made it because coming from Oregon we just had our biggest snowstorm in 100 years just 24 hours before I was to board the plane. And it wasn’t just like a moment in time—it continued snowing all the way up until the point I was supposed to get out of my driveway. So like any good keynote speaker, I called the airport to get a shuttle and make sure I had my ride. And they were laughing at me. They told me, “Are you kidding? All of our cars are buried under snow. We can’t get them out of the airport parking lot.”

So that’s when I knew I was going to have to start digging my own car out. I started with a dust pan and a broom, a garden shovel and rake. Then we boiled hot water and poured it down the driveway and also my partner held a blow dryer, like some sort of thing from home depot, against the front of the car. Luckily we were one of the few homes with power. So this went on for hours and hours and hours. Finally my neighbors felt sorry for me and one guy did bring a snow shovel and helped us along.

So 2:00 am yesterday with a flashlight in my mouth, I’m trying to put chains on my Prius tires while my partner who never loses his temper starts raising his voice. “Sweetie!” kind of screaming, “Honey!” Luckily the snow absorbed all our voices so the neighbors didn’t wake up. I really had to get to the airport starting to move at 3:00 am because we could only travel at eight miles per hour because of all the downed trees and power lines that were hanging. I was kind of moving at the speed and the clearance of a lady bug in my Prius toward the airport. When I got to the airport I wasn’t at all sure I was going to actually leave in a plane, but my plane was the only one that was not canceled. Thank you United!

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