Most heart-wrenching e-mail I have ever received. From a true hero, Dr. Varun.
Hi, der. I don’t know how thankful I am to you for writing that article on physician’s suicide. I really wanted to hug you after reading it. I had really rough day after seeing 130 outpatients and around 60 admission emergency in a 12 hour duty. I work as a final year MD internal medicine resident in one of the busiest hospital in India. I saw a part of myself in every page of your article Just couldn’t stop reading the article. It is 3:00 am in the morning here and after a physically and mentally demanding day of work and studies reading your article was the best thing today.
It takes me 5 hours by flight to reach my home from my hospital. I have my wife and 6 month old son (whom I been with for 15 days since his birth) at home. I work day in and out just to be with them once in 3 months. I don’t see my colleagues smile, I hear my patients misery every day. I smile and crack jokes even when I am sad so that I can bring some joy into my patients sorrowful life.
Today I saw this patient who died, married with a son, the only earning member of his family …….his widow just wouldn’t accept that he was dead. She kept talking to him. I just didn’t know what to feel ….. I was numb for a minute thinking what if that was me …. And the kid is my son…..
I see deaths everyday in ward …..I don’t know if you would believe me, but 4 deaths per day in a single ward of 40 beds overcrowded to 125 patients admitted at a time. Two patients on a bed, two lying together on the floor. Poverty, misery and pain all around. I have declared 12 patients dead in a day during one of my duties. I just don’t feel death anymore, just don’t feel human. My uncle died recently, I felt nothing deep inside just some memories and that is it.
I write this mail hoping that the way I survive my day would help you in helping others.
I always wish my colleagues and say hi when I see them in the morning. Say hi to everyone from my ward sweeper to the guard in the ward. I never eat alone and always make sure I share my food. I always smile whenever I talk to my patients. I hold their hands when I talk. Listen music whenever possible. And everyday whenever possible I talk to my wife, father, mother, and brother (all of them are doctors).
But still this profession demands too much from us. I have thought about giving up and suicide a thousand times ……the misery was too much for me to see 12 people die in a day. The only thing that keeps me moving forward is my family and friends.
I appreciate what you are doing. It took me 4 hours to write this mail. It is 7 am in the morning. But your article was worth it. Thank you. Thanks a lot…..
Pamela Wible, M.D. is a family doctor who is dedicated to physician suicide prevention. Please be kind to your doctor. The life you save may save you. Photo credit: Dr. Varun (and his newborn son)
This courageous physician blows a whistle on the human rights abuse in hospitals. Doctors forced to work 8 consecutive days. No sleep. No access to food. Doctor forced to work in ICU after having seizure. Is this the care you want in American hospitals?
The hospital administration and the national hospitalist company that I worked for made this agreement that the shifts would be 24 hours. And they would be consecutive 24-hour shifts. And there were only 3 of us dong this job for 365 days a year—seven on and seven off. So seven 24s [that's a 168-hour shift!] You know, that works if you are just taking call at night, but really what it became was you’re up at the ER at night. And you would see the poor exhausted ER doc who would come on at 7:00 am and get off at 7:00 pm while the next guy came in.
You’re exhausted too and you’re like, “They’re going home and the nurses are going home. Okay, I can do another night. Okay, I can do another night.” Then you are staying through and maybe you get done at 1:00 am and you’re like, “Should I eat? Should I shower? Or should I sleep? Well, you know if I shower then they might call me again from the ER.” So everything just gets let go and then you try to go to sleep and then you get called back again and then you see that ER doc and nurses are going off shift and the new army of people would come in and you’re still there. And then the same thing that night.
And it just got worse and worse. It got busier and busier. And the way that they do that is they hire J-1 visas [international medical doctors] and they’re locked into 3 years. So I was one of the very few people that was not a J-1 visa at this job. And they’re locked in. They can’t complain because they’ll lose their visa. So I tried to speak up eventually. And I waited a while to do that because I wanted to make relationships first and I waited. I stayed there for almost two years. And I finally brought it up and tried to have some meetings and tried to be politically correct and tried to document the conditions.
I slept in the hospital. I showered in a broom closet, a little closet in the CCU [Cardiac Care Unit]. The cafeteria closed at 1:00 pm so usually we’d miss breakfast because you’re on the wards at 7:00 am and breakfast is at 7:00. And then you’d often miss lunch because it is really hard to get off at 12:00 pm to go get something to eat. And then the cafeteria was closed because it’s a small hospital so you’d have no access to food. And then you’d think, “Well, I’m gonna go out to get a Whataburger, or whatever, (which I hate eating) and then you wouldn’t get out.” And then you’d say, “Could we have access to food?” And they’re like, “Well, you outsiders, you come in and you tell us how . . .” It was insane.
We had case management meetings in the morning with the case management team and on a transition day if I was going off my shifts and a new doctor was coming on the shifts we would all meet together. And the case managers were all fresh because they worked an 8-hour shift. They worked hard. But if they worked over 8 hours they were on overtime. So we’re doing these 24s and they’re coming on fresh. And then their boss would say, “Oh, Dr. __ is so irritable. Why is she so irritable?”
So I’m sitting there one day. I’m just exhausted going off of a 3 or 4 day stretch and my new boss . . . There were only 3 of us and everybody kept leaving. The program director left so they asked each one of us if we wanted to be program director and we, of course, anyone who had smarts said, “Uh, no way.”
So who gets to be program director? It’s the newest guy who’s like 28 and J-1 visa nice-enough guy. So he comes on and he tries to manage this program in addition to being the new family medicine grad at this hospital where we were the ICU doctors. No cardiologists. No pulmonologists. Sick, sick, sick, sick, sick patients. So he’s managing all this.
He comes on to the shift and we’re having this meeting. Or maybe he was going off the shift. I can’t remember. [She believes he had been working 8 days straight] He starts seizing. Literally seizing. You know, having a seizure. And they allowed him to work that day. In the ICU. And we are unsupervised in the ICU. It is us and only us. In fact as an internist I even got called into OB there because there’s nobody to do critical care for hemorrhages. So it was exciting, but you have got to be on your game. And I tell you what—when you have worked 36 hours you are not on top of your game and there is nobody else overlooking those cases. And, of course, the patients don’t know that you’ve worked that long. Would they fly in a plane if the pilot had been flying for 36 hours—and seizing?
UN Declaration of Human Rights: Article 5. No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. Article 24. Everyone has the right to rest and leisure, including reasonable limitation of working hours and periodic holidays with pay.
Pamela Wible, M.D. is dedicated to ending the human rights abuse of medical students and doctors so patients can receive the health care they deserve.
This summer I did the [ALS] ice bucket challenge. But I’m challenged by another disease. A disease so scary people won’t say it out loud. A disease so frightening that doctors are afraid to talk about it. A disease so feared that physicians falsify death certificates, families deny the cause of death, and most victims’ names are hidden for eternity.
Every year we lose over 400 doctors to suicide. That’s like an entire medical school—gone. I was suicidal. I survived. But I lost both men I dated in med school to suicide. And 3 doctors in my town in just over a year to suicide. Each year over 1 million Americans will lose their doctors to suicide. These are just the physician suicides I heard about this year:
Gregory Miday, MD, internist, by scalpel in bathtub
Vincent Uybarreta, MD, surgery intern, by belt hanging in closet
Kaitlyn Elkins, third-year medical student (and her grieving mother, Rhonda Elkins), both by helium overdose
David Brooks, MD, family doctor, by standing in front of train
Phillip Henderson, MD, III, fourth-generation obstetrician, by gunshot wound
Rafael, family doctor in South Carolina, by overdose
Gregg, internist in California, by overdose
Pediatrician in Oregon, by gunshot wound in park
Vascular surgeon in California, by carbon monoxide
Urologist in Oregon, by gunshot wound
Larry, anesthesiologist in Oregon, by overdose in hospital closet
Edward, family doctor in Oregon, by gunshot wound in clinic
Otolaryngologist in Kentucky, by jumping from balcony
Orthopedic surgeon in California
Anesthesiologist in Washington
Female third-year medical student in Michigan, by overdose
Another medical student in Michigan
Male radiation oncologist
Male colorectal surgeon in Texas
Male medical student
Male pediatric surgeon, by gunshot wound in bedroom
Male family medicine resident
Male doctor, by gunshot wound
Male family doctor, by drowning
Male second-year medical student in Washington, by gunshot wound
Cardiologist in California, by gunshot wound in laundry room
Female family physician in Iowa
Male anesthesiologist, by overdose in hospital
Another male anesthesiologist, by overdose in hospital
Male medical student
Male doctor in Oregon
Female medical student
Another female medical student
Male medical student
Male doctor, by heroin overdose
Male pediatric intensivist, by plane crash
Male family physician, by gunshot wound
Female obstetrician, by driving off bridge
Male obstetrician, by gunshot wound
Male internist, by overdose
Male medical student, by jumping
Male medical student, by gunshot wound
Male family physician in Alabama, by gunshot wound in driveway
A married physician couple, by overdose
Another married physician couple, by overdose in hotel room
Female doctor in Wyoming
Male allergist in Oregon, by jumping from hospital parking garage
Rudolph Fajardo, MD, pediatrician, by gunshot wound
Bruce Feldman, MD, surgeon, by jumping from bridge
Captain Michael Ryan McCaddon, MD, Army obstetrician, killed himself at Tripler Army Medical Center in Honolulu
Nicholas DePizzo, MD, family doctor, by gunshot wound in office
Henry Norrid, DO, by gunshot wound
Male radiation oncologist in Illinois, by jumping from window
Leonard Graff, MD, by gunshot wound in clinic
Jonathan Drummond-Webb, MD, pediatric heart surgeon, by overdose
Harry Reiss, MD, urologist in NYC, by overdose in clinic
Carrie Largent, second-year medical student
Douglas Meyer, MD, gastroenterologist, by jumping from hospital window in NYC
Daniel Gunther, MD, pediatric endocrinologist, by inhaling car exhaust
Hamza Brimah, MD internist, by gunshot wound
Male doctor, by overdose
Male doctor, by gunshot wound
Medical student in Boston
Another medical student in Boston
A third medical student in Boston
A fourth medical student in Boston
Male otolaryngologist, by hanging himself in hotel room
Male anesthesiologist, by overdose at the hospital
Male family doctor, by gunshot wound
Male doctor, by gunshot wound
Male pediatric endocrinologist, by hanging
Male medical student
Male physician in Oregon, by gunshot wound
Male obstetrician, by gunshot wound
Male family medicine resident, by gunshot wound
Male obstetrician, by gunshot wound
Female physician, by overdose
Male family physician, by overdose
Male obstetrician, by overdose
Male psychiatrist, by gunshot wound
Female medical student, by gunshot wound after failing exam by 2 points
Emergency room physician in Oregon
Female anesthesiologist, by overdose
Orthopedic surgeon in Seattle, by gunshot wound in car
Male physician, by jumping from hospital
Another male physician, by jumping from hospital
Male urologist, by stabbing himself in abdomen in hospital parking garage
Female medical student
Female otolaryngologist, by carbon monoxide
Surgeon in Houston, by gunshot wound
Male medical student
Male urologist in Oregon
Urology resident in Portland, by walking in front of a truck on highway
Female physician, suicided after not getting a dermatology residency
Last week I delivered this talk twice at the American Academy of Family Physicians Scientific Assembly in Washington DC, and I also presented it to third-year medical students at The Commonwealth Medical College of Pennsylvania. It is fully transcribed here. Every medical student and physician needs this information. Please share widely. You may save a life.
Dr. Wible: Welcome to Physician Suicide 101: Secrets, Lies & Solutions.
I’m a family physician born into a family of physicians. My parents warned me not to pursue medicine. So I went to medical school. Ten years later, I’m unhappy with the direction of my profession (and I’m not the only one). Then I get this crazy idea: what if I ask for help? Not from the profession that wounded me. Just from random people on the street. So I hold a town meeting and ask patients to help me—design an ideal medical clinic. I promise do whatever they want as long as it’s basically legal. That’s going out on a limb.
I’m a go-out-on-a-limb kind of doctor. In med school I protest the dog labs and I’m sent to the office of the Dean—who diagnoses me with “Bambi Syndrome.” In residency I’m caught giving patients recipes for kale salad. I’m sent to the office, reprimanded for not getting approval from the patient education committee. I’m 46 and I’m still handing out unapproved kale salad recipes—now I’m taking on physician suicide. My therapist calls me the “Dr. Kevorkian of Medical Taboos.” Before my wedding, my dad actually made my husband promise to keep me out of jail. “Always pushing the limits,” Mom says, “always going out on a limb.” Today I invite you to join me.
Here are the official learning objectives. Bottom line—I need you to take action. I don’t care what you do as long as you do something.
Why do we do what we do? To save lives. Why did you go to medical school? Seriously. Why spend your 20s studying while all your friends are at parties? To make a difference—to save lives. Why are you here? To get CME? See the Smithsonian? Rediscover your joy, your calling? What is your calling? Why are you a family doc? They recruited me for pediatrics, but I kept asking why? Why this kid’s got asthma? Why the parents smoke? Why they live next to an incinerator? I’m a family doc because I can’t stop asking WHY? So why are you here? You had 20 choices, why attend this talk? Maybe you lost a colleague to suicide, a friend in med school. Maybe you are struggling now. Maybe (like me) you just want to know why our colleagues die by suicide at twice the rate of their patients. And you want to save lives.
The fact is each year we lose over 400 doctors to suicide—that’s like an entire medical school gone. I lost both men I dated in med school to suicide. In my town, in just over a year, we lost 3 doctors to suicide. One doc in town lost 7 colleagues to suicide! (In what other profession, can you lose 7 colleagues to suicide?!) This year over 1 million Americans will lose their doctors to suicide. Why? To know why someone has died, we perform an autopsy. With suicides, we perform a psychological autopsy:
Today—for the first time—I share my results from 4 psychological autopsies:
This is Vincent. He’s 2. He framed this photo to give his parents at his med school graduation. An adored first grandchild, a joyful little prankster who made everyone laugh. His Aunt Edna told me in catholic grammar school Vincent has his feet up on the chair in front of him. Sister Agnes comes by and tells him to put his feet down. He replies, “I have to keep my legs up!” She asks why. He says, “I have varicose veins.”
Here’s Vincent at high school prom. An athlete and artist, compassionate, sensitive, gregarious, yet private. A compulsive perfectionist. Always a good kid. Never any addictions. Just a straight forward normal good guy, according to his mom.
Here’s Vincent’s med school graduation photo—just 25 years old and 2 months after starting a prestigious surgical residency in New York City, he dies by suicide. Why? Look at his eyes. Notice the difference between his childhood photos and his medical school graduation picture. He looked happy and healthy before med school. What happened during Vincent’s medical training? I interviewed several of Vincent’s family members to find out.
His mom says he became disappointed, disillusioned. He lived near the hospital, but drove an extra 45 minutes home at every chance he had just to sleep in his own bedroom. He lost a lot of weight and his jokes and laughs were gone. His family was concerned, but they thought it was the adjustment to a demanding profession.
Vincent told stories of how surgeons publicly humiliated interns. How he and his partner fell asleep leaning against walls in the hospital while waiting for their patient’s turn for a scan. He spoke of his doubts about saving this one guy who jumped out of a building when caught raping a young girl who was also being treated in an adjacent room. He spoke of the sisters—victims of a car accident—brought to the ER, stunned him for a moment because they looked like his mom and aunt who often travel together without seat belts. Vincent took a belt and hung himself in his closet. The note he left:
* * *
This is Greg at 3.
Outgoing, curious and clever. He always got along great with adults. At 5, he goes on this family trip to visit his great aunt—a nun at a convent. A French professor, she asks Greg to give her a word he would like to hear in French. He says, “Guacamole.”
Greg as a child with his mom.
Greg graduating from med school. A pianist, painter, poet, a real Renaissance man much beloved by his patients. Greg sent this e-mail to his parents, both physicians, one year before he died
Subject: Piece of My Mind
Read this if you have time. It resonated with me especially well this morning. I like these two paragraphs:
I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many ‘civilians’ would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable.
How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction?
Greg was the only one in his family who struggled with anxiety, depression, and alcohol. After an outpatient program his third year of med school, he was sober until his second year of residency. A brilliant clinician, never impaired at work, but a Physicians Health Program (PHP) mandated a 90-day treatment facility 300 miles away, where Greg felt marginalized, belittled and was 3 months behind in completing residency. He felt if he were a banker or lawyer he wouldn’t have this forced upon him. He hid his depression and substance abuse and carried a lot of shame. Just 24 hours before his death (he had relapsed), he met with his psychiatrist who arranged admission at a local rehab facility. Greg notified the PHP who held the keys to his license. They disagreed with his psychiatrist’s safety plan. Greg felt humiliated, cornered, and killed himself.
His mom wrote this letter to the editor of The New York Times in response to a physician suicide article last month. You may recall the article about the two young doctors—interns who jumped to their deaths in late August from their Manhattan hospitals. Greg’s mother writes:
An unacknowledged predicament for physicians who identify their struggle with substance abuse and/or depression is that they are often placed under the supervision of their State Medical Board’s Physicians Health Program. My son, Greg, was being monitored by such a program. He took his own life at age 29, one week before he was to enter an esteemed oncology fellowship. His final phone calls were to the PHP notifying them of his use of alcohol while on vacation, a disclosure he had previously described as a ‘career killer.’
These programs, which often offer no psychiatric oversight, serve as both treating and policing agencies, a serious conflict of interest. Threatened loss of licensure deters vulnerable physicians from seeking help, and may even trigger a suicidal crisis. Medical Boards have the duty to safeguard the public, but the assumption that mental illness equals medical incompetence is an archaic notion. Medical Boards must stop participating in the stigmatization of mental illness. We cannot afford to lose another physician to shame.
I read 12 pages of online condolences. This anonymous entry stands out: “Thank you for being nice to even the unpopular kids in high school. May your soul rest in eternal peace.” Greg looked out for the underdogs, but what happens when doctors are considered underdogs? Who looks out for us? Do we get the care we need? Greg didn’t. Greg transected his bilateral radial and dorsalis pedis arteries with a scalpel in the bathtub, candles lit, music playing, some wine, vodka, surrounded by family photos. Greg’s note:
* * *
This is Kaitlyn and her mom.
A sweet, good girl. Kaitlyn never gave her parents any problems, though she cried when she lost at Monopoly. From the time she started preschool, she never needed any help with her homework or anything. At 3 years old, she had to get glasses. Her parents took her to the big medical center where the doctor asked lots of questions. He’d look at the parents for answers, but Kaitlyn answered them all. The doctor was amazed.
This is Kaitlyn in high school. A deep thinker, an artist, a poet. I met her extended family in North Carolina. They claim, “Kaitlyn was one of the happiest people on this Earth.”
Here’s Kaitlyn in med school. Just 23 years old and beginning her third year. An introvert with social anxiety, Kaitlyn always had a few close friends, but none in med school. Everyone was busy studying and “people just went their own way,” she told her mom. She was desperately lonely. Her perfectionism worsened. She went on a strict diet, started running marathons, and lost a lot of weight. She ran like 10-12 miles before class everyday and still excelled in med school, acing her Step One exam. Unfortunately she didn’t live to celebrate her results because she completed her suicide—a helium overdose—like a well-planned school project. She left a 2-page suicide note in which she claimed lifelong depression, but hid it to protect her family and herself.
As an aside, I believe that Kaitlyn suffered less from depression and more from “feeling different and isolated” due to her high intellect. She was raised in the poorest county in North Carolina was the smartest person around. Maybe she had hoped that when she entered medical school she would finally be with her tribe—a social circle of more like-minded intellectuals. But medical school rarely creates an environment for students to develop intimate friendships with one another. These young sensitive and brilliant people are left to fend for themselves in survival mode with an overwhelming amount of material to master in a short time with little emotional support.
I can guarantee that many medical students cry themselves to sleep at night in their pillows. That’s what I did nearly every night my first year of medical school. I cried so much that one morning my eyelids were sealed shut. I couldn’t see anything when I woke up. I had to feel my way to the bathroom. Is this they way a civilized society trains its healers?
Kaitlyn’s mother published her daughter’s suicide letter in a book she wrote about Kaitlyn. An excerpt:
Kaitlyn’s grieving mother—unable to recover from her daughter’s death—died by helium overdose one year later. I attended her funeral last month.
* * *
Here we have a spunky, happy 2-year-old girl who stood up to adults negotiating her way out of a bedtime, a bath time, and persuading her dad to get Slurpees and candy bars for dinner. Life was good until her first year of medical school.
Just a few months into med school she develops major depression due to what she calls “barbaric and inhumane medical training.” Years later, fed up with assembly-line medicine, she’s suicidal. The only difference between these cases is she survived and she’s on stage speaking today for the other 3 who can’t.
* * *
Our cases are not isolated. All brilliant, sensitive people who felt alone in a highly competitive and inhumane environment. All sleep deprived working or studying over 80 hours week. All hid their depression and appeared highly functional until their suicides and all left notes because we’re trained to do and we’re so darn responsible!
The secrets start with victims who are ashamed. Families remain silent to safeguard their reputations. Physicians hide suicides from patients who never find out why they can’t get a follow-up appointment with their doctor who left the clinic so suddenly. Physician suicide is medicine’s darkest secret and our code of silence is maintained by layers of lies.
Reductionism is the opposite of holism. Reductionism leads to body-mind-spirit disintegration. While reductionist medicine has led to scientific advances, it’s fatally flawed. It separates us from our hearts and souls which is what gives our lives meaning and keeps up wanting to live here on Earth. Professional distance is far from protective. Vulnerability is strength. When we’re authentic with our patients and ourselves, we build resilience and connections with other people here on Earth. And the suicide coverups . . .
It’s a medical game of truths and lies. Death certificates are miscoded even when there’s a suicide note! A suicidal hanging becomes asphyxia, a suicidal overdose is suddenly an accidental overdose, a self-inflicted gunshot wound is officially an accidental gunshot wound, a suicidal motor vehicle accident is just another motor vehicle accident.
Meanwhile those in the know whisper blame-the-victim questions: Was he not doing well academically? Did she got a low board score? Are we selecting the wrong people for medical school? These questions focus blame on the victim, not the health care system.
So what are the solutions? Solutions come from individuals or institutions inside or outside of medicine.
Non-medical individuals—the general population of non-physicians. Except for Greg’s parents who are aware of the occupational hazards of medicine, families had no idea their child was at high risk of suicide until the police called to tell them their child was dead. Compelled to act, Vincent’s mom starts a foundation that sponsors an annual lecture on mental health for residents at Vincent’s school. Kaitlyn’s mom writes her heart out online in a blog and on social media sites. She supports struggling medical students online. Ultimately she publishes a book examining suicides in the exceptionally gifted like her daughter. She asks all 171 medical schools in the United States if they would like a copy. Thirty got a copy. Should we rely on grieving mothers—suffering in isolation as were their children—to solve this?
Non-medical institutions like the media could instantly stop the secrecy and alert the public about the high risk of suicide in medical students and physicians. Because sending your child to medical school or a surgery residency is not like sending your kid to law school or to cashier at Walmart. It’s more like sending your kid to Iraq or Afghanistan and it requires a completely different level of vigilance.
I spent two hours on the phone with Kaitlyn’s dad the other week. A sweet, sweet man. Not the kind of guy who would ever blame anyone else for his problems. I asked, “If Kaitlyn worked at Walmart, would she and your wife still be alive?” He says, “Yes. Medical school has cost me half my family.”
Medical individuals—that’s me and you questioning these deaths, and Greg’s mom seeking audits of PHPs for fraud and abuse.
Lastly medical institutions. Kaitlyn’s school started a fund in her name for donations to their wellness center so that presumably Kaitlyn’s classmates could seek the help that she didn’t. Vincent’s yearly lectures continue. But what else can we do?
Let’s compare how we handle physician suicide with say. . . umm . . . human rabies. Since the 1900s, annual human rabies deaths in the US have gone from 100 to just 2 per year. How did we do this? Not by grieving mothers launching “rabies awareness campaigns.” Not by donations to a wellness program. Not by a yearly lecture series. And not by miscoding rabies deaths as the flu!
Here’s how we did it: medical institutions took this on methodically using science—primary, secondary and tertiary prevention strategies.
We spend over $300 million annually to prevent human rabies. The cost per human life saved ranges from $10,000 to $100 million. What do we spend on medical student and physician suicide prevention?
Since eradicating the terrestrial canine rabies variant in the US, 90% of the 2 deaths per year are transmitted from wildlife—mostly bats then raccoons. If we can deliver over 6 million oral rabies vaccine baits yearly to raccoons (and I’m talking about guys dropping these from low-flying planes over the Appalachian Mountains and dudes running through dark urban alleys), we’ve gotta be able to do something for med students. Right? We’re way easier to find than raccoons. We’re already in the hospital!
Right now while I’m standing here on stage we are actively tracking rabies in raccoons, bats, skunks, foxes, cats, dogs, cattle—even mongooses in Puerto Rico, but we’re not tracking the numbers of suicides in medical students and doctors. Do you ever get the feeling you might be less important than a Puerto Rican mongoose?
Here’s what scares Kaitlyn’s dad. Now I want to preface this with something else I learned about Kaitlyn’s mom who also suffered from depression. I asked Kaitlyn’s dad when his wife developed depression. Get ready for this. He told me it was after she completed nursing school in her 30s when she worked in a nursing home with a high census in which she was witnessing unsafe conditions for patients—and staff. She was normal before nursing school. Okay. Normal. Like medical students who start med school with their mental health on par with their peers. Then something happens during medical training to doctors—and nurses.
This is what really scares Kaitlyn’s dad. He tells me, “I got one child left. She’s in nursing school. I hope she’ll beat the odds. I can’t handle another.” This man has a real risk of losing more people in his family than we lose in a year to rabies! What are we doing? For him? For medical students? For us?
Here’s what we should be doing:
First: prevent healthy medical students and doctors from getting conditions that lead to suicide. Second: Early diagnosis, referral and therapy. Third: help suicidal medical students and doctors rehab.
Let’s start with a holistic and humane medical education that de-stigmatizes mental illness.
The goal: help medical students be the self-actualized doctors described in their personal statements for which they were accepted into medical school in the first place. We know how to grow happy and healthy people. This is not some sort of secret. Follow Maslow’s Hierarchy of Needs. Begin by meeting physiologic needs with adequate sleep, time to eat and bathroom breaks. Simple. Basic. Ya know? Meet safety needs with a safe workplace without bullying or abuse. Social needs can be met by allowing students to feel part of a community with time for intimate friendships. And finally, self esteem needs. Medical students should feel honored and respected for their contributions and level of mastery in medicine. Not belittled. Not shamed. Not pimped. Not hazed. This is 2014.
Meet social needs with Matched Mentorship Programs. Use match.com technology to match first year medical students with second years—and physicians within their specialty of interest. Match Day should be the first week of medical school. Don’t wait until fourth year for Match Day. These people need friends. Now. We should not allow medical students like Kaitlyn to die from extreme loneliness.
Meet safety and self-esteem needs using nonviolent communication (NVC) which is based on the premise that every behavior is an attempt to meet a need. We can try to change others’ behaviors by using shame and blame or we can listen and educate compassionately. If you hear a doctor raise his voice at Vincent, would you pass by unsure of what to say? Meet the conflict with confidence using NVC using a simple 4-sentence sequence—a stated observation, feeling, need, and request.
Observation: I heard you speaking loudly to Vincent.
Feeling: I feel concerned, because . . .
Need: I need everyone be respected in this hospital.
Request: Would you be willing to lower your volume and speak with more consideration for Vincent’s feelings?
Meet social and self-esteem needs with Balint groups. These are small group clinical case presentations that focus on the patient-physician relationship and enhance our ability to care for patients. Balint groups are usually led by a doctor with some experience in facilitating these groups and/or a psychologist/counselor. These groups are easy to start. If you want some training, I’d recommend the American Balint Society. Has anyone here ever done a Balint group? (Lots of family docs raise their hands in the room).
If Vincent could have attended a Balint group, he might have shared, “This week I saw a 30-year-old male who presented with injuries after jumping from a 3-story window after raping a young girl. I was tachycardic and I had trouble maintaining eye contact . . .” Vincent would have the chance to share feelings and get feedback in a safe environment. Offer Balint groups at lunchtime and meet physiologic needs too since students do need to eat! Ya know, give them a Subway sandwich or something to share.
Early intervention begins with a yearly physical. In Kaitlyn’s second-year physical her doctor might have said, “I see you lost 20 pounds since first year and you’re getting up at 5:00 am to run 10 miles before class. How are things going for you?” Every medical school needs a 24/7 helpline staffed by medical students. We learn to do blood pressures, ear and throat exams on each other, let’s learn emotional support too and give first and second years the real-world experience of being on call—for each other.
Build in support for transitions from second to third year, traumatic cases, and medical errors. We’re all going to make an error and we should not have to feel like a failed perfectionist who can never be a good doctor. Again, medical students and physicians should not be left to cry themselves to sleep in their pillows alone at night with no support. That’s inhumane.
We need physician-specific rehab for substance use, physical, and mental health issues that are unique to physicians and medical students.
Even medical students and residents with physical ailments feel ostracized from the group. The message usually goes something like this: “Let us know when you’re off the ventilator so we can put you back on the call schedule.” What kind of support is that? Rehab should be flexible, in town, with part-time work options. You know what kept Greg from drinking? His work. He loved working. Why send this excellent doctor 300 miles away? Greg shouldn’t leave town for inpatient rehab if local, output rehab is effective. And rehab should be non-shaming. When Greg called his mom (a psychiatrist) for help, his PHP therapist said, “Oh, you had to call your mommy?” What kind of treatment is that? We need personal physician oversight so our vulnerable colleagues are not abused and traumatized when they need help.
Would they be alive today? YES. Their deaths were 100% preventable. Every day we don’t take action, we lose another Kaitlyn, Vincent, or Greg.
So what will you do?
1) Will you talk about physician suicide? If you lose a peer, will you hold an M&M conference or perform a psychological autopsy? A group of cyberspace docs recently asked me, “What gives you the right to perform a psychological autopsy? To go through these victims’ autopsies and suicide notes?” Well, these families reached out to me. I didn’t go looking for this. I didn’t even know I was doing psychological autopsies until I discovered the term in a suicide article. FYI: families with suicided children are eager for someone to take a sincere interest in their kids’ deaths. Would you be willing to honor their children? And prevent future deaths among your peers?
Another gang of cyberspace docs wanted to know what kind of training I have that allows me to do these psychological autopsies. Do I have some sort of certificate that gives me the right to do this? I have no training. But my mom’s a psychiatrist. My dad’s a pathologist. Maybe that means I’m a natural at psychological autopsies.
What training do you really need? Just take an interest in your dead colleagues. The only question you really need to ask is “WHY?”
2) Will you stop the bullying and abuse? We can all reach out to faculty who use shame-and-blame teaching, call attention to the violence, and offer alternatives. We do not need fear-based teaching to learn how to be healers.
3) Will you learn nonviolent communication? Vincent was inserted into violent crime scenes. Why speak violently to one another? NVC can reduce the trauma of our traumatic jobs. Let’s learn and then teach NVC. It’s easy. I learned in an hour online. Plus my ex-husband’s last girlfriend teaches it and I hired her for a private lesson. Takes about an hour—or at max two. Every medical school, hospital, and clinic should teach their students, physicians, staff—even administrators and CEOs how to speak with kindness and compassion.
4) Will you start a Balint group? All medical students and physicians would benefit from a weekly lunchtime case conference, a structured release valve for the trauma they have witnessed. Vincent and his peers could have processed their feelings and eaten.
I teach a biannual physician retreat in which physicians often (spontaneously and without prompting) start crying about cases from years ago. One doc in her late 50s broke down about a miscarriage she witnessed over 20 years ago. She was just so happy that she could finally cry about it! She hadn’t been able to cry in years. Really? We’re just supposed to just shove all this down day after day, week after week, year after year with no release valve? You can’t tell your spouse. Cases are confidential. Plus you’ll wear out your spouse. There’s a reason most people don’t go into medicine. They can’t handle this stuff. We can IF we have a way to process our feelings in real time before we start plotting our suicides.
Please (I’m begging you) start a Balint group in your clinic or hospital. You could save lives.
5) Will you reach out to troubled colleagues? Doctors like Greg won’t just come up to you and say, “I’m suicidal.” But he might say, “I had a rough day.” (That’s doctorspeak for I NEED HELP!) When docs e-mail me their troubles, I call them back immediately. Sometimes 30 seconds after they hit the “send” button on their computers. They’re shocked. I respond,” When you’re on call, you call patients immediately. Right? Why don’t we do that for each other?”
6) Will you be a mentor? At the time of Kaitlyn’s death she was dating a man in Michigan who was a 99% match on OkCupid. Kaitlyn needed a matched mentor in her own town—at her own school. Someone to watch over her. Could that have been you?
There’s so much we can do. I don’t care what you do as long as we do something. So will you go out on a limb to save a doctor? To save the people who dedicate their lives to saving others? And if you are suffering, will you seek help?
Standing at the town meeting, I went out on limb. I didn’t just tell folks I was an unhappy doctor. I told my entire town I was depressed and suicidal. I begged strangers to help me design an ideal clinic. And define an ideal doctor. I had lost my way. They told me an ideal doctor has a big heart and a great love for people and service. And an ideal clinic is a sanctuary, a safe place, a place of wisdom where we can learn to live harmlessly, listen with empathy and observe without judgement. It’s a place where a revolution starts where we rediscover our priorities with relaxed appointments, smiley-face balloons and fun flannel gowns—a lady at the town meeting even volunteered to make them for me.
Then a bearded guy in the back of the room raised his hand and asked a question I’ll never forget, “Is it possible to find a doctor who’s happy?” I collected 100 pages of written testimony, adopted 90% feedback and we opened one month later. That was 10 years ago. I’m happy now. All because I asked for help.
Pamela Wible, M.D., pioneered the first ideal clinic designed entirely by patients—the original “Patient Centered Medical Home.” She was once a suicidal doctor and now dedicates her life to helping medical students and doctors who are disgusted with, depressed by, and feeling suicidal about their once-beloved careers in medicine. There is hope! Come to the next physician retreat (premeds & med students welcomed). Learn more about the ideal medical care movement in Dr. Wible’s TEDx talk.
I believe we choose our parents before we are born. I hit the jackpot.
I picked an unlikely pair—a radical feminist and a guy named Ted Krouse. Mom wasn’t home much (she was finishing up her psychiatry residency) so I became head of the household. Dad always kowtowed to the strongest woman in the room. I was two at the time. I never had a bed time or a bath time and I sent Dad out on midnight runs to 7-11 to get us Slurpees and chocolate bars for dinner. Since I rarely bathed, I ended up with dreadlocks. Dad turned my poor hygiene into a neighborhood contest. The kids on the block lined up in our living room. Dad gave $1 to anyone who could move a comb through my hair.
Ted was basically a single dad. Every so often he’d place an ad in the newspaper for a live-in nanny. A slew of women from all over town showed up at our doorstep to compete for the position. Dad lined them up across the piano bench and onto the couch. Then he’d point to me and my baby brother on the floor and ask, “Do you think you can handle them?” None lasted long. Some quit mid-shift, I think a few on their first day.
With unreliable child care, I’d accompany Dad to work. The morgue was like our secret clubhouse. Dad would open the stainless-steel doors to the cooler and say, “Good morning! Is anyone home?” He’d prop me up and introduce me to all his patients.
Then we’d head to the Camden methadone clinic. As clients came in, Dad introduced me “This is Pamela. She’s a doctor-in-training. Show her your track marks.” Then he’d tell them a secret: “Ya know, I got an addiction too.” Opening his drawer, he pulls out a bag of banana-flavored marshmallow candies. “I love Circus Peanuts, but I’ve had this unopened bag in my desk for two years. I don’t allow my addiction to control me.” I’ve never seen anyone eat these—except Dad. His secret to longevity: cigarettes, vodka, and Circus Peanuts. At noon, he gave lunch money to clients in need. He hands ten bucks to a transsexual woman and tells us to “go have fun.” So I spend the afternoon on a street corner with recovering heroin addicts, eating pizza, and learning Spanish slang from a sexy Puerto Rican woman with huge biceps.
At nightfall, we head to the jail, where we evaluate drunk drivers. While most kids are preparing milk and cookies for Santa, Dad and I spend Christmas Eve seeing 30 prisoners on night shift. We set up our cots in our own cinder-block room with Dr. Krouse displayed prominently on the door. I watch drunk black men staggering in and out of our bedroom all night long. Dad introduces me as a “doctor-in-training,” then tells the men, “Lean forward and breathe toward me.” He sniffs them for alcohol. Dad was the City of Philadelphia’s human breathalyzer. Ted’s nose saved lives and kept Philadelphia streets safe for over 20 years. My father had nearly 14,000 guys with DUIs breath and burp in his face—until they replaced him with a mechanical breathalyzer in the 80s.
We spent nights at the state psychiatric hospital hanging out with schizophrenics plus we were on call for the Fire Department. We’d end up at midnight apartment fires in crime-ridden neighborhoods. To keep us safe, Dad bundled us up and locked us in the car. I’d wake my brother, unlock the door, and drag his little body over firehoses until we were stopped at the police line. The magic words, “I’m Dr. Krouse’s daughter” and they’d let us wander off right toward the fire.
Dad, you shielded me from nothing. You exposed me to sexuality, racism, poverty and death—all before starting grade school. Thank you for your courage. You weaned me from the bottle and let me to drink from the cup of truth. You never censored me. And you never censored the world around me. I didn’t understand the value of your gifts until I was older.
On birthdays and holidays, when most girls get chocolates or flowers from their fathers, you sent me a Valentine’s Day box of Godiva gallstones (the most beautiful gemstones that you retrieved from real gallbladders just for me). You sent me gift boxes with heart valves, kidney stones, and prosthetic testicles—along with my birthday cards.
You called yourself my first boyfriend and told me our solid relationship would pave the way for a lifetime of loving relationships with men. Actually Dad, you made it kinda difficult for me to find a date. Strong, eccentric, fearless females who prefer spending Saturday nights in the morgue aren’t in high demand. While my Wellesley classmates were seeking husbands at Harvard and M.I.T. frat parties, I took the night shift at the homeless shelter where people mistook me for a light-skinned black woman.
You treated all people with honor and respect whether they were black, white, Puerto Rican, whether they were on heroin, alcohol, or homeless, or dead. Ever nonjudgmental, with a heart of compassion. Your benevolent service inspires me every day to serve people with an open heart. I still do house calls just like you and—like you I’ve never turned anyone away for lack of money.
I want you to know that the people you exposed me to were more than your patients to me. They became family. You made the entire world my family. And you made me a family physician to the world.
You took me to work and now I’m taking you with me. You are scattered in stories throughout my books, on national TV interviews, on websites, and blogs—and in all my talks to medical students and physicians. For 46 years I tagged along with you. Tag along with me for the next 46. Our adventures have just begun. Rest up. You’re coming with me next week when I present my work on physician suicide to 5,000 physicians in Washington, DC. Dad, I know you really, really wanted me to be surgeon general, but our professional influence has surpassed the confines of the office of surgeon general. I hope you understand. I don’t need medals or fancy titles. Medicine is an apprenticeship profession. And I learned from the best man out there.
YOU. The one-and-only Dr. Theodore Krouse—you are SO eccentric. Ya know, you’re the reason I’ve never owned a TV. Nothing on television can ever touch my real-life adventures with you.
So I want to thank you. For everything. For never hiding the truth in happily-ever-after children’s stories. For never sheltering me in a hollow make-believe world. For introducing me on day one as a doctor-in-training. As healers, you and I are fueled by tragedy and we are forever intertwined in our pursuit of tikkun olam—a more perfect world.
In the end, we are all just spiritual beings having a brief and finite human experience. Thank you for choosing to share your human experience with me. It’s been an absolute blast. But above all—more than anything else—I need to thank you for never taming my hair or my spirit.
Bless you. Be free. . . .
Pamela L. Wible, M.D., is the founder of the ideal medical care movement. To learn more about ideal medical care, watch her TED talk. Here she delivers a final TED talk for her father, Dr. Ted Krouse (9/13/23 - 10/10/14).
Pamela, get this—after saying that I’d need to make up for my ‘lost time’ on production since I’m quitting my job and taking off for our retreat, the Head Suit calls me today and begs me not to quit. I’m talking shamelessly groveling, tail-between-the-legs PLEADING in this phone call:
Suit: “Don’t leave. Please. I don’t want you to go.”
Me: “Um, okay.” Wasn’t sure what to say to that. Totally different attitude than when we were talking 3 days ago about my subpar “production.”
Suit: “Is there anything that would keep you here? Anything?”
Me: “Well, um, honestly?”
Suit: “Of course! I want you to be totally honest.”
Me: “Okay. Then no.”
Pamela, this whole process is crazy-making. I feel like I’m in my abusive first marriage all over again! But at least I got nice flowers and makeup sex out of that!
After reading her above e-mail, I reply: “Can I publish this?
Her response: “Oh HELL YEAH!!!! I would be completely and utterly honored. But please include one final note:
Word to the Wise:
Don’t ever try to mind-fuck a psychiatrist.
Pamela Wible, M.D., is a family physician and founder of the ideal medical care movement. Watch her TEDx talk on ideal care. If you’re a doctor, join the physician teleseminar and learn how you can stop taking this shit and start practicing real medicine. Photo by GeVe.