I am writing to you with great sadness, but with relentless determination to ignite change. I am a doctor with a disability. Two years ago I began residency training in pediatrics. The privilege was overwhelming as I stood a doctor in the very halls where I had been wheeled in as a patient with a brain tumor. I couldn’t believe that I had actually made it, that I was alive, and that I would be given the great gift of caring for others. I fulfilled my dream and my promise to my neurosurgeons—that one day I would walk through the doors of this hospital as a doctor.
But my dream has slowly been taken away from me. I fought to complete my pediatric training, but my program fought harder to discriminate, retaliate, and punish me for my differences. Early on I began experiencing significant difficulty with sleep deprivation. I was threatened with termination for requesting formal ADA accommodations and told I would be fired if I proved unable to endure 80-90 hour work weeks, 28 hours of continuous work without sleep, and up to 14 days without a break. My body was resilient as I had survived 2 brain tumors and 3 brain surgeries, but was left with permanent (yet mild) physical challenges. My residency program was well aware of my needs but chose to label me as weak. I was humiliated and criticized as unfit to practice medicine. I tried to tough it out and power through the grueling schedule I was forced to work. I would be fired if I didn’t.
I recall arriving home one day after a 28-hour shift and being unable to walk up the stairs to my house. My body was shutting down, my morale was nearly gone, and I needed someone to understand. My oncologist became increasingly alarmed that I was being bullied for my disability, yet it was one of the graduate medical education administrators who took my situation into her own hands as she went over the heads of my program. After being denied formal ADA accommodations for 2 years, I was finally granted a work-hour adjustment.
Then all of the sudden I experienced an abrupt shift in my evaluations. Suddenly, my performance was well below average with a knowledge base of “sand, not stone.” I was warned that I was too polite, too nice, and that I needed to become more arrogant if I was going to make it as a doctor. My program director explained to me that she “didn’t care how residents conducted themselves as long as they didn’t kill anyone.” I was told to “turn off my moral compass” and that “you do not have to be a good person to be a good doctor.” My program was searching for any way to push me out through completely absurd claims regarding my performance. All of these complaints began when I started working a “humane” 60-hour work week. The constant shaming and harassment was unbearable. No longer willing or able to tolerate discrimination, I resigned at the beginning of my third year.
Residency programs are not interested in training physicians to be humanists. They are interested in creating machines. I am not a machine. I am a human being who wants nothing more than to devote my life to this University as my doctors at this hospital are the reason I am alive. I want to be the kind of doctor that could tell a child in pain that I understand because I have felt this pain. Being a patient has made me a better doctor. I want to be a walking example of the amazing work of my pediatrician, neurosurgeons, and oncologists. My program has taken all of this from me. The irony of my story is palpable: I pursued pediatrics—to care for those who are vulnerable and suffering—and my program has not been able to care for their own doctors.
It is indescribably crushing that the same system that gave me my physical life back has now taken away my life’s purpose. My superiors have belittled me for the very deficits that inspired me to become a doctor—my compassion, love, and dedication to my patients. In trying with all that I have to give back to the institution that has saved my life and to devote myself to making the lives of children better, my dream has been destroyed, my time as a patient has been devalued, and my heart has been broken.
Here’s a quick review of health care delivery basics:
Primary care – Stuff you can get handled with your primary care doctor in your neighborhood. Example: ingrown toenail.
Secondary care – Stuff your primary care doctor refers to a secondary specialist down the road. Example: colonoscopy.
Tertiary care – Complex stuff you need to deal with at a big-city hospital. Example: lung transplant.
Here’s the problem: In modern medicine we’re holding primary care hostage to a tertiary care delivery model.
If you’re getting a lung transplant you need a 5-story hospital with helipad, medical team, insurance coding/billing software (you actually need insurance to cover the $500,000+ bill) and all sorts of special machines and complicated equipment. If you’re getting a colonoscopy, you need one person to shove a tube up your butt in a simple office with a few staff. If you’ve got an ingrown toenail you need one primary care doc in one tiny exam room with a pair of scissors.
When we force ingrown toenails and buttholes to subsidize 5-story hospitals, helipads, medical teams, and insurance systems, we create incredible inefficiency and expense. In fact, all that crap is not only unnecessary, it just gets in the way and makes your $100 toenail or $1000 colonoscopy cost hundreds and thousands more!
When we force primary care to pay for the infrastructure of tertiary care medicine, we end up with assembly-line medicine in which patients are forced through 7-minute visits. Both high volume and price gouging are required to pay for the unnecessary helipads and hospitals for your ingrown toenail.
I’m a family doctor and I’ve been delivering primary care to my community for decades. I’ve removed ingrown toenails and metastatic lung cancer. I’ve cared for psychiatric patients and complex neurologic conditions. In fact, I can deliver care for 99% of what ails my patients right in the comfort of my 280-square-foot office. Just two chairs. One exam table. And no staff.
All I really need is my brain. And my brain tells me we must stop allowing buttholes to design primary care delivery in America.
Attention doctors: If you’re not attracting your ideal patients, don’t blame them. They probably have no idea how to find you. That’s your job.
So who do you really want to see? What patient population makes you excited to jump out of bed every morning? Seriously. Who the heck do you want to spend 40+ hours per week hanging around?
Are you interested in seeing parents of kids with ADHD in Washington who are curious about vegetarian diets but feel confused in the grocery store surrounded by tofu? What about hippie women with chronic yeast imbalances intrigued by homeopathy in Oregon? Attracted to diabetic divorced long-haul truckers with erectile dysfunction passing through Interstate 81 in Virgina?
Anyone getting excited yet? Then keep thinking . . .
Do you love obese republican women in Missouri with fibromyalgia? Or would you rather spend your days with runaway teens in Memphis? Or retired gluten-free wealthy women in Dallas? It’s your choice. Remember there IS someone for everyone.
So who’s YOUR ideal patient? If you don’t know, they won’t know either.
Here are three doctors who have figured it out. And three patients who—against all odds—have found their ideal doctors. These are doctor-patient matches made in heaven! And all these folks couldn’t be happier.
Parents of kids with ADHD in Yakima, Washington, who want to try vegetarian diets love Dr. Yami Lancaster, a pediatrician who does house calls where she even dives into the family pantry, refrigerator, and freezer to remove hidden culprits that sabotage health. She accompanies overwhelmed parents food shopping, guides them to healthy foods and may even cut the family grocery bill in half! Then she’ll lead a private cooking lesson at their home that will keep the kids busy in the kitchen so parents can finally relax.
Hippie women with chronic yeast imbalances who want to try homeopathy in Happy Valley, Oregon, adore Dr. Kat Lopez, who believes in the body’s innate ability to heal. No more phone trees, cafeteria-style waiting rooms and five-minute quickie visits with doctors who look sicker than patients. Dr. Lopez spends a full hour with clients who leave with a comprehensive plan to restore health using nutrition and lifestyle so they can wean off drugs. Naturopathic doctors, an acupuncturist, and massage therapists are on site as well as a holistic dental hygienist, and a hyperbaric oxygen chamber.
Diabetic divorced long-haul truck drivers with erectile dysfunction passing through Raphine, Virgina, now have their prayers answered with Dr. Rob Marsh. The big truck stop off Interstate 81 offers diesel, a hot shower, a good dinner, and now a doctor. This small-town family doc needed more patients to keep his solo practice afloat. With a underserved patient population of 20,000 long-haul truckers who are never home long enough to have their own family doc, Dr. Marsh took the job! He treats everyone who walks in and even does U.S. Department of Transportation physicals. He gets paid mostly in cash (win-win!) and now the truck stop owner plans to open an pharmacy.
Pamela Wible, M.D., is a family physician who pioneered the first ideal clinic designed entirely by patients. She loves helping others find joy in medicine and live happily ever after in their ideal clinics too. (Photo credit: Shutterstock). For a free teleclass on how to attract your ideal patient, please contact Dr.Wible.
Today we celebrate hardworking Americans, the 40-hour work week, and safe working conditions with parades, picnics, and a day to rest.
Except doctors. They’re still at work.
At the height of the Industrial Revolution, Americans worked 12-hour days every day in unsafe factory-like settings with lack of breaks, water, food, and fresh air. Immigrants were treated even worse.
Industrialized assembly-line medicine now forces doctors to work up to 168-hour shifts with lack of access to food, sleep, fresh air, and breaks. Do the math: a 168-hour week means no sleep all week.
America’s hospitals and clinics are filled with doctors who are not only subjected to poor physical conditions; they also suffer from mental health issues. Suicide is an occupational hazard in medicine where bullying, hazing, sleep deprivation is the norm.
Why should you care? Why not just enjoy your picnic with the family and sit back and watch the parade?
Because if you get in a car wreck on the way to the picnic you may be treated by a physician in the ICU who is constipated, hypoglycemic, and has not slept in 168 hours. Is this the person you want controlling your ventilator?
In 2011 doctors-in-training in America were supposed to be protected with 80-hour work week restrictions (maximum 24-hour shifts). However, these work-hour restrictions are unenforced. I hear from doctors in training all the time who are terrified to declare their actual number of work hours per week (120+) because of harassment and other repercussions that may end their careers. Oh and J-1 Visa (foreign doctors) can be fired and deported if they complain about unsafe working conditions.
The Accreditation Council for Graduate Medical Education (ACGME) imposed these more stringent resident work-hour restrictions in 2011, prompted, in part, by a 2009 Institute of Medicine (IOM) report and based on substantial evidence that sleep deprivation in medical residents increases the risk of medical errors for patients and serious harms for residents (including motor vehicle accidents, needle stick injuries, and depression). Now there are proposals to roll back these resident work-hour restrictions.
Are you a physician who has been injured by sleep deprivation and unsafe working conditions? Are you a patient who is outraged that your physician is working 24-hour shifts? Or 168-hour work weeks? The time to speak up is now. Sign this petition to demand safe working conditions for doctors then leave your comment on this blog.
Pamela Wible, M.D., is an investigative reporter and whistleblower who advocates for physicians and patients injured by unsafe working condition in America’s hospitals and clinics. Have a story to share? Please contact Dr. Wible.
In August 2016 more than 600 people came together in 11 cities across America to stand in solidarity—and to say “no more” to medical student and physician suicide. Here are some of the speakers from the event in New York where Dr. Wible delivered the keynote address.
(Dr. Wible begins speaking at 18:20. Transcription below)
I’m Dr. Wible. I want to share some personal stories that I think will be really memorable after today. A lot of times if we just approach [physician suicide] from a supratentorial angle it doesn’t hold our attention and make things memorable into the future [the statistics can be overwhelming and frightening]. Just telling personal stories will help you access just a little bit of what my life is like right now. So I want to share a friend of mine with you, a friend of mine named Cheryl, a new friend that I just made a few months ago. Cheryl belongs to a club that nobody wants to be a member of. It’s an online support group that I started for parents who have lost their children to suicide in medical school and beyond (so residency as well). There are more people joining our group every week and month because we continue to lose (unfortunately) medical students to suicide. Cheryl lost her only child, Sean, just 3 months ago. For the longest time I couldn’t talk to her because she was crying and couldn’t even speak on the phone. Now we talk for an hour and a half or two hours at a time. She is an amazing woman and I want to just share, like many of the parents who have lost their children to suicide in medical school, she was a very attentive mother. She was very forthright about wanting to be on top of her child’s safety (wearing helmets on the bicycle, training wheels, seat belts etc.) She had no idea that when she sent her child to medical school that would potentially be one of the most dangerous environments for his health. She actually did not know any of this until she got a call from the police that was they day after Mother’s Day when Sean took his life.
Sean Petro at his Navy graduation. Courtesy: Cheryl Collier
A little bit about Sean: he’s just kind of a quirky, highly intelligent, compassionate guy who is really just a man of integrity and honor. He spent Mother’s Day with his mom and at the end of the day he stood in the doorway with his stepdad Russel and he thanked him for always being there for him and then he drove back to USC/Keck and late that evening or early the next morning he hung himself in his closet. And nobody saw this coming. There were no warning signs that anyone in his family could pick up (or his classmates). It just came completely out of the blue and this is what we hear and what I hear often. In the majority of these cases the person is doing fine, they are passing their tests, they’re doing well in medical school, they may even be at the top of their class and out of the blue they are gone.
It is very important for us to understand that there is a group of people who are aware of this problem and it is the medical profession. We, the medical profession, not necessarily each one of us but the medical profession itself has known about physicians being at high risk of suicide since 1858 in England when it was first reported. And 158 years later unfortunately we have not done enough to stop these deaths.
I can speak from personal experience. But first back to Cheryl, I made the point that she had no idea that physician and medical student suicide was such an issue. I had no idea. I never had a class in medical school about this. We didn’t talk about it. They never told us in residency and I went to a residency that was amazing, it was a family medicine residency that really focussed on behavioral health and mental health and nowhere in my residency experience do I recall ever hearing that I would have a high risk of suicide and depression myself. So when I was 36 years old and I developed suicidal thoughts as a physician that lasted for a 6 week period and were pretty intense, I thought I was the only one.
I thought I was the only one who cried my way through my first year of medical school. Everyone else looked like they were fine on the outside. I thought I was the only one who felt like my soul and heart were getting ripped out of my body during my medical training because nobody else seemed to talk about this. I thought I was the only one who felt like my only value to my profession was as a revenue-generating robot in an assembly-line clinic. Because everyone else was going to work and not complaining. It is a very lonely place to feel like you are the only one. It puts you into a spiral downward.
Come to find out I’m not the only one. As it turns out both the men I dated in medical school (once they became successful physicians) they both died by suicide. In my small town it turns out that we have lost 8 physicians to suicide. And nobody was talking about it. And I consider myself a pretty sharp person. I’m a very existential thinker and I have no fear of death. So it actually took me (remember I was 36 when I had my brush with suicide) it took me until I was 44 years old to realize that this was a crisis.
It was a day that I will never forget. It was October 28, 2012 at 2:00 pm and I was sitting at the memorial service for the third physician that we had lost to suicide [in 18 months] in my small town. I was sitting behind his 5 children and his wife. And I just started counting on my fingers the numbers of suspicious deaths and suicides among doctors that I knew about. In a very short period of time I had used all 10 fingers and then what was I going to start doing counting on my toes? I was overwhelmed with the thought. I felt like I had just fallen into this investigative reporting story and I needed to determine more about what was really going on and deliver this message to the world somehow and to solve this problem.
So immediately I did have to leave the memorial service early because I was teaching a business course for physicians that evening. When I arrived there I asked everyone, “How many of you have lost a colleague to suicide?” Every single hand was raised. Then I asked, “How many of you have considered suicide?” Every hand in the room was raised (including mine) except for one female nurse practitioner. I don’t need any more proof than that this is a huge problem. Even last week (just 5 days ago) we lost another bright medical student to suicide. That was on Wednesday. And I just learned today (on my way over here I got an email) there was an anesthesiologist who died that same day by suicide. So we lost 2 people last Wednesday. A lot of these [suicides] are covered up. I don’t know who they all are, but I do have a list of 320 plus cases that I have accumulated over the last couple of years of tracking these. It is just devastating.
I feel like these should be never events. We should not be losing medical students in medical school to suicide. We should not be losing our anesthesiologists who are dying of overdoses in call rooms. You know it is very interesting where people decide to die by suicide. They often do it at their medical school or at the hospital at the place where I feel like they have sustained the injury, where they are associating their pain.
We can change this. We can change the culture. We don’t have to continue this. It is up to you. I love that you are embracing each other as family. It takes proper leadership from your medical school. I’ve heard wonderful things about your social worker. That is just fabulous that you have so much support here. That must be you [pointing to the social worker]. Awesome!
And I really want to shout out to the DO schools. You are way ahead of allopathic medicine on this. You are amazing and you’ll notice that all of the vigils that were held at medical schools were at osteopathic medical schools. So I want to congratulate you for that. It is about walking the talk.
I don’t want any of you in here to have a classmate or your own parents receive a phone call from the police at midnight that something has happened to you. What will stop this? You have to look out for each other. You are brothers and sisters in medicine and it really is a family and I want to encourage you all to relate to each other like family. To be caring and loving and look out for one another. If you see someone who is isolating, please reach out. A lot of these students who die by suicide are living alone in apartments off campus and they are isolating. They are studying in isolation and nobody has seen them for a while. Please look after each other. Maybe have a buddy system.
It is just very sad for me to be on the phone with parents who have lost their only child in medical school and to hear them recognize that this has been a problem for over 100 years, that we have known about this and nothing has been done and that their child could have potentially been saved. So I want you to join with me and be vocal about this. There is no shame in talking about mental health.
I want to share a story that I have just received in an email from a woman named Michelle that really puts it into perspective what’s missing in most medical schools today. And by the way a lot of the things I am suggesting are cost free. Like be nice to each other, look after each other, go out for tea, talk to the social worker who is here and who is an amazing resource. I don’t know if you all have had any sessions with her. She is a resource and she is here for you and it would be wonderful for you to access the wonderful people who are around you who do want to help you. Please don’t feel alone. Here’s what happened to Michelle who wrote me this letter. She is a medical student and she writes, “I was less stressed in Afghanistan as a as a combat medic in a war zone.” That’s pretty intense. I’m just going to read a few sentences she wrote me:
“During the first few missions, I was scared for my life. After that, I became numb to that fear and just focused on making sure I was able to save my guys’ lives if we were attacked. The stress was incredible, but I had their back, and they had mine. In an unsafe country and a future filled with uncertainty, I felt secure because we supported each other.”
Isn’t that amazing? Even if you have gunfire, even if you have an incredible number of tests, even if you have all these things that are so stressful, if you have each other it makes it possible to move through the most painful events. Having each others’ back is so important.
One other thing I’ll share. When I realized physician suicide was a problem I started speaking and writing about it. Then the flood gates opened. You may notice that when you start volunteering your mental health struggles, you’ll have many people that come up to you and want to share their mental health struggles. It is the normal human dynamic. Once you find somebody who is talking about what you are afraid to talk about, it releases you to start speaking.
As soon as I started blogging about [physician suicide] I started getting letters and phone calls from physicians and medical students from not only the Unites States but from all over the world. I am basically running a suicide hotline out of my house. You guys I am here for you: 541-345-2437. Call me anytime. IdealMedicalcare.org contact me anytime. I return every single phone call, every single email. Some people reach out to me because they don’t have amazing social workers that they feel comfortable with or counselors at their school and they don’t want to reveal this to their dean. They trust me and so they call me because I’m out of state and they feel that I won’t tell their school on them and that sort of thing. So whomever you feel comfortable with, please reach out.
It’s been really interesting. I have received so many letters that I published a book calledPhysician Suicide Letters—Answered, that is full of letters from physicians who are still alive (like a print version of my physician suicide hotline). Only 6 of the people have died and they died before I interacted with their families and the letters are from their mothers and siblings. I brought several copies of this book free for you all to have. They are up on the piano. I brought 25 copies. So if this is something that you feel like would help you, please take a free copy when we are done. What is interesting about this book is that when it came out it was banned by an anesthesia department at a prestigious east coast hospital, and they had just had a suicide of an anesthesiologist. Why do I bring all of this up? First of all when you ban a book it just increases readership so it kind of backfired. Censorship is not a solution for a medical problem. If we hid the bodied of people with Ebola or Zika, we would never solve it. So it is very important to be able to speak about this.
In closing I just want to share 3 things that have not been working so well and 3 things that I think will work well.
1) Censorship, banning books, and using euphemisms are not going to help us solve this. If we say “my classmate suddenly passed this weekend” and we do not say the word suicide out loud it makes it very hard to solve a problem if we won’t even say it out loud. I want to encourage you to talk about suicide like we talk about high blood pressure or diabetes or anything else. It is a medical condition that we can solve if we are not afraid to say it out loud.
2) Zero tolerance for bullying and hazing and abuse at our medical schools, our clinics, and our hospitals. The bullying, hazing, and abuse that goes on in certain medical schools and residency programs (yours seems like a really great place, but I’m sure you’ve heard from other people who have been bullied and abused) that is not a great way to stabilize your medical students’ mental health. Right? We are not allowed to bully kids in elementary schools and hazing has been outlawed in fraternities. Certainly we should have a zero tolerance for bullying and hazing and abuse at our medical schools, our clinics, and our hospitals.
3) Stop labeling victims with “burnout.”Don’t blame, shame the victims. This is a dangerous and slippery slope. Sometimes we use a word that I actually can not stand—burnout—to describe people who are having trouble, who can’t keep up. Burnout is a victim blaming and shaming term that makes the individual feel defective when actually it is a system’s issue often that is causing this. Maybe they are having sexual harassment at work or bullying or they haven’t slept for 72 hours. These sorts of things are very destabilizing. Recommending that victims just take a deep breath and do yoga is kind of hard to do if you are in a work environment that is inhumane. I want to draw your attention to the idea that we not label and blame the victim because they will start to feel defective. When you feel defective like you can’t keep up you start to feel like maybe the world would be better without me. I want to encourage you to embrace each other and not to label each other because you want to empower one another not destabilize someone with a term that they makes the individual feel different. Lift them up with you.
In summary, #1 Tell the truth. We don;t have to censor or ban anything, Just tell the truth. #2 Please a zero tolerance for bullying, hazing, and abuse in our medical schools, clinics, and hospitals. If you see a colleague who has been pimped to the point of crying, who has had a scalpel thrown out them in the OR, please stand up for your colleagues. Do not allow other people to be injured during the training process. #3 Please do not label people with terms that are not real helpful, like burnout. It might make them feel worse.
My final statement is that we really need to have awareness and action. That is what is important right now. Physician suicide is a public health crisis because more than one million Americans lose their doctors to suicide each year. It is a public health crisis.
If physician suicide were an infectious disease it would be on the evening news every night and we would have a body count.
People ask me all the time, “How many people are actually dying by suicide?” We don’t exactly know. We are kind of probably underestimating it when we say 400 doctors die each year (and that is not even counting medical students). So I would like us to have a body count like we do with every other disease and we should be talking about this on the news, with each other. there is no shame in talking about this and certainly parents like Cheryl and Michele (that you will see in this Do No Harm movie trailer) deserve to know. These parents had no idea their children were at high risk of suicide. This is informed consent. Medical students should know before they enter medical school that this is a risk. Parents should know because we would interact with each other differently and we would be more likely to save lives. So thank you very much for standing with me on this.
Join the more than 600 people who stood together in solidarity in 11 cities to say “no more.”
Pamela Wible, M.D., is a family physician who has dedicated her life to ending the medical student and physician suicide crisis. Need help? Please contact Dr. Wible. Video credits Jaryd Frankel, TouroCOM. Photo credits Cheryl Collier, Elnaz Mahbub.