Physician PTSD—Are you a victim?

Physician PTSD

Pamela Wible: We just got back from leading a physician retreat and this is actually my 16th physician retreat. Sydney, you’ve been co-facilitating these retreats with me for years and I just want to check in with you on something that I’ve noticed. I’m realizing more and more how many physicians are suffering with PTSD, even residents and medical students at the very earliest stages in their careers. Are you noticing that?

Sydney Ashland: Pamela I just got off the phone with a physician who specialized in emergency room medicine who is haunted by PTSD, survivor guilt, feels a total disconnect from the practice of medicine. I just find it so tragic that the very people who save hundreds and thousands of lives yearly are left as mere shells of the people they used to be. They’re no longer able to relax, feel joy. They’re stuck in this never-never land of misery and pain. It’s just so maddening to hear the same stories over and over when it feels so preventable. We just have so few medical professionals that are trying to serve so many people. I know that administrators feel crushed by the numbers, the health issues, the lack of consistent healthcare. They’re trying to stay competitive and profitable. I understand that.

Schools are trying to stay cutting edge, but no one is really coming up with those commonsensical answers, those interventions that can keep our medical warriors, our medical geniuses in the field. Instead, everyone shows up as victims. The hospitals, the medical schools blame high overhead. Insurance companies join in that refrain as well, and there’s a lack of innovative programs and strategies to address these needs. Everyone is passing the buck and the problems are not only exacerbated but they seem like they’re escalating. Is that your perception?

Pamela Wible: Yeah. I’m seeing more and more, and even younger people who are trying to flee their profession before they’ve even started practicing really, right?

Sydney Ashland: Yeah. I think part of that is that these medical schools are trying to prepare these students for the unbelievable pressures and stresses that they’re hearing about and know about in the medical field. Instead of really resourcing medical students and residents, it’s depleting them, it’s leaving them scarred and stressed and with post-traumatic stress disorder. Then they can’t practice medicine. They’re not going to survive post-residency. That’s what I find so, for lack of a better word, I’ll use it again, so tragic. It’s a tragedy.

Pamela Wible: I definitely want to go through some of the, maybe top five things that I’ve noticed that lead to PTSD in medical students, residents and physicians. There really is a lack of leadership in medicine. What’s ending up happening is you have the old guard just preparing people to do it the same way we’ve always done it because that’s how we’ve always done it. The world is not what it was 20, 30, 40 years ago. There are so many things that have changed in medicine. To have this knee-jerk reaction to lock medical students back into this regurgitation-memorization cycle when we can obviously access things at our fingertips. We need to have the joy of learning. We need to stop pushing people to continue in a system that’s obviously failing and imploding, right? We need new thinking. We need new ways of training physicians. We need to stop terrorizing them and violating their human rights.

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Sydney Ashland: Exactly. We need leadership to do that. I feel a call to action for those in leadership positions right now to be brave, to find their courage and to begin to address these problems. For those that are in the rank and file who feel that conviction, that energy of activism within themselves to step forward as the new leaders, because that’s what it’s going to take in order to create the change that is necessary. I know that you and I, outside of the system, are trying to serve as leaders for those who feel like they need to leave the systems in order to not only live their dream but live their passion with attending to patients and serving their communities.

Pamela Wible: Right. I just want to add in there. I haven’t really left the system. I am practicing medicine in alignment with my highest values. I still take insurance. I submit my own claims. I practice like any other physician would practice, but I am autonomous in my own clinic. Obviously, I’m a truth seeker and a truth speaker and I’m not afraid to tell the truth. That has made me, to some people, a little bit fringy. As far as how I practice medicine, I’m very conservative in my own practice. And I love to encourage others, nurse practitioners, PAs, physicians, veterinarians, others in healthcare to really take the reigns back on their profession and practice an alignment with the highest values that brought you here.

Sydney Ashland: Excellent clarification. Excellent. That is exactly what I feel convicted to join you in doing.

Pamela Wible: Before we launch in, I don’t really have these in any particular order, but I thought we could address the top five things that we both feel lead to physician PTSD. One thing I’d like to preface this conversation with is that it’s so very important to tell the truth. I think many of us scurry around the truth using words that are absolutely inaccurate like burnout. That’s a word that I do not use because it’s a victim blaming and shaming term that does not address the true reason for people feeling so discouraged and so unable to keep up. I want us to dive into the truth here and to encourage others who are listening to this to also use accurate and precise terms for what is causing the suffering in your life. Because if we didn’t do that with patients, we’d misdiagnosed people all day long if we just dance around the periphery with a double speak and inappropriate terms, right?

Sydney Ashland: Exactly. Yes. Give me some truth.

Pamela Wible: Yeah, I’m going to just give an overview here of the five that I came up with and then we can dive into each one. The first one in no particular order. Actually, the way I did organize these is chronologically. The order in which a new student, a premed, first day of medical school coming in would experience these things that would lead to ultimately a life that’s very disturbing and fits the criteria of PTSD.

Physician PTSD Quiz
Number one is medical training. We have a fear-driven medical education model that teaches us by terror. I want to address that. Number two, human rights violations that include chronic sleep deprivation, hazing, bullying, lack of access to food, water, inability to see your family, take care of your own bodily functions. Number three, vicarious trauma. Of course, high risk specialties like emergency department and neonatology and such are going to feel more of this vicarious trauma. Number four, losing colleagues to suicide. I bet there are hardly any physicians out there who do not know of another physician who has died by suicide and you’ve probably not been able to properly grieve the death of that suicide. This is terrible. You’re going back to work every day feeling at risk yourself and I want to address that. Number five is just the chronic toxic workplace environments that we are in every day. Shoved in this assembly-line, big-box clinics, which are dangerous for our own health and the health of our patients.

The first one here, medical training, I thought I’d share two stories that came to me. There are letters that I’ve received. These are actually published in the Physician Suicide Letters—Answered book, which is available free as an audiobook if this would help you. Anyone out there, you’re welcome to download this. Number one, this is from a retired specialist in her 60s who wrote me:

“I was happy, secure and mostly unafraid until med school. I recall in vivid detail the first orientation day. Our anatomy professor stood before an auditorium filled with a 125 eager, nervous, idealistic would-be healers and said these words. ‘If you decide to commit suicide, do it right so you do not become a burden to society.’

He then described an anatomical detail how to commit suicide. I have often wondered how many auditoriums full of new students heard these words from him. I am sure someone stood in front of us and told us what a wonderful and rewarding profession we had chosen. I do not remember those words, but I do remember how to successfully commit suicide with a gun.

One month later on the eve of our first monthly round of six exams in one day, I had my first full-blown panic attack. I had no idea what was happening. I thought I was losing my mind. I took a leave of absence and made up excuses. I returned untreated with maladaptive compulsive behavior, completed med school and survived the public pimp sessions and all the rest.

No one ever suggested that the process was brutal or the responsibility frightening and no one offered us help. I have maintained contact with only one colleague from med school so I do not know how the others fared.”

I just want to say I have chills reading this like every time. This is teaching by terror. What do you feel? I’m going to read another letter in a bit, but I want to know what do you feel?

Sydney Ashland: Well, one of the things that stuck out to me was the fact that this person had no idea what was happening to them. In the midst of this full-blown panic attack, they felt like they were losing their mind. When we are in a terrorized situation, and you talked about medical training as fear-driven and teaching by terror, we lose our ability to respond and we enter a place of high reactivity so that we are reacting to. That’s the whole panic attack.

She was having this huge reaction rather than being able to respond in the situation. We call our paramedics and firemen—first responders. We don’t call them first reactors. I don’t want somebody working on me who is in a reactive state because they are going to be so infused with adrenaline and stress hormones that they’re going to be in a high state of reactivity and not necessarily responding in a way that is thoughtful, that allows for pause, that helps them respond from a decisive place rather than reacting from a triggered place. That’s what stood out to me in that first story.

Pamela Wible: It just makes me wonder. She’s retired now, but gosh, how did she practice medicine? Did she carry this with her when treating patients? Was she still impacted by this?

Sydney Ashland: I’m certain she did. Absolutely. As we go through all the labels that you have identified as a part of the PTSD cycle in the medical field, we will, I’m sure, touch on other areas that she experienced, because you know she experienced human rights violations. You know that she experienced some vicarious trauma and then what are the characteristics when we are in those states.

Pamela Wible: Right. The next one I want to share is from a surgery resident. Again, that would be a high-risk specialty of witnessing all sorts of trauma. What I noticed when reading this, it brings up the fact that our attendings have been mistreated themselves during training. They don’t even have the teaching skills that they often need to handle these high-stress environments and teach in a compassionate way. I mean there’s multiple victims here, right?

Sydney Ashland: Absolutely.

Pamela Wible: Lisa, a surgery resident in New York writes me,

“I began my residency in California and during that time was very depressed, abused within my training program. My depression impacted my performance and I was eventually fired. I was lucky enough to find another position and continue my training, however, some days I feel my depression and despair returning primarily when I feel my career has been irreparably damaged by my departure from my first residency program.

Those feelings were initially tied to hazing and bullying that are an integral part of the educational program there. Sometimes, I can still hear those attendings in my head saying things like, ‘Watching you operate is like watching a retarded monkey.’ Or, ‘Do they ever teach anatomy at your medical school? Our students know more than you.’

It’s paralyzing. I am reaching out to you for two reasons. I’m interested in eradicating the abuse in medical education. I’d like to have a career in academics and to influence policy regarding the treatment of trainees. More importantly, can you help me make the flashbacks stop? Can you help me not worry so much about my future? Can you help me with my depression related to my change in career trajectory? Thank you for your work.”

I think when I first received this and I saw the flashback word was when I first realized this is PTSD.

Sydney Ashland: Full-blown PTSD. There’s an excellent book that Peter Levine has written about Waking the Tiger. He is an individual who worked at Walter Reed hospital for years with vets who have PTSD. One of the things I would encourage this woman and anyone listening is that in reading that book, you will be given some exercises that help you with the flashbacks. Where you can enter that place in your trauma and tell your brain a different story.

You have to be in a thoughtful place. You should be in therapy or have at least a supportive network to help you during this phase of healing, but the flashbacks can stop. You can move from reactivity to a responsive and thoughtful life. You can return to taking care of yourself and not continuing the abuse cycle, because so often people like Lisa leave their surgery residency, depriving themselves, treating themselves poorly, having circuitous and habituated thought patterns that are intrusive. So that even when they’re successful, what they are haunted by is that classmates taunting the time they made a mistake, that depression that ended up in them leaving medical training even though they continued somewhere else. It can be helped. There are interventions.

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Pamela Wible: Is there anything else that you have noticed in your many years working with medical students and residents that would. . .  Any other examples that you see of PTSD and medical education . . .

Sydney Ashland: Well, one of the ways to combat this PTSD is to stop it. For every student or resident who has the courage to stand up and refuse to be bullied, refuse to accept hazing, to stand shoulder to shoulder when you have a professor or someone who is teaching or training you who tries to pimp you in some way. That you stand shoulder to shoulder and refuse to participate as passive observers sort of witnessing this person’s torture and trauma and instead speak up, answer for that person. Let your voice be heard. It’s that truth telling. I think that’s very important.

Pamela Wible: For those of you who would be concerned about being the only one standing up there is power in numbers. If everyone in your residency class or a significant part of your medical school class stood up, did a petition, went to the dean, theree are examples where professors have been fired for mistreating the students. You absolutely have to stand up either individually or as a group or you are perpetuating human rights violations on the next generation of trainees. It’s very important.

Sydney Ashland: Yes. Tell me more about your perspective on human rights violations and how that impacts PTSD, Pamela.

Pamela Wible: Well, when reading the United Nation’s Declaration of Human Rights, it is rather shocking that so many of the things that are included in there are frequently articles that are broken in first-world hospitals in the way that we train our medical students and residents and physicians. It’s just heartbreaking to me.

I do think that we need to use the proper terminology—human rights violations. This is not something that I’m exaggerating or embellishing. This is straight out of the UN Declaration of Human Rights. Feel free to read about it yourself online, but here are some of the things that I’ve mentioned earlier.

Chronic sleep deprivation, that’s a torture technique that’s used in war time to extract from people all sorts of information in a weakened state. I don’t think any of us want a physician working on us in such a state. Hazing, bullying, sexual harassment, racism, women that are being belittled and told they should have gone into social work instead of neurosurgery because they are crying with a family member who lost their child after a surgery. This is just absolutely ridiculous, and are human rights violations against genders, against ageism, against . . .

Sydney Ashland: Whole classes of people.

Pamela Wible: Whole classes of people they’re going to call little snowflakes. People don’t make in into medical school without determination, intelligence, compassion and to beat this out of them—a love of learning and a love for humanity—is absolutely the wrong way to train people. I’m going to give some examples of two people who’ve written to me here lately.

One says, “I had married the year before residency, and for the first two years, I was either at work or asleep, so I didn’t see my wife. It was the start of the erosion of the relationship that led to divorce years later. I also suffered permanent health problems, some extreme sleep deprivation. Prior to residency, I slept fine eight hours a night and had regular bowel movements. Since my internship, I developed lifelong severe insomnia and went for decades on four to five hours of sleep per night as well as severe constipation using the toilet about every five days.”

Sydney Ashland: Wow.

Pamela Wible: What do you think about that?

Sydney Ashland: This is just triggering in me so many memories of conversations I’ve had with people who also have experienced human rights violations that have ended up resulting in seizure disorder due to lack of sleep or low, low blood sugars. Both of those I have experienced in conversation with someone or observed as their experience when they were sleep deprived and had not eaten for an excessive period of time. It’s just unbelievable to me that the disruption of our basic human needs, those daily activities, the ADLs that we need in order to be categorized as a human being is so absent in training and especially in residency. It just is unconscionable to me.

Pamela Wible: I recently was speaking at a residency program. They brought me in for wellness day. One of the psychiatry interns there actually said on stage with me with the microphone in hand that she had only seen her newborn for six waking hours during the first six months of her residency.

Sydney Ashland: Wow.

Pamela Wible: This is ridiculous. This is causing lifelong problems in now another generation of children of physicians who are neglected and maternally deprived.

Sydney Ashland: Right. As well as contributing to long-standing permanent mental health issues, because you cannot experience sleep deprivation, hazing, bullying at that level with so little support.

Pamela Wible: That’s seven years. Medical school plus a minimum of three years of residency.

Sydney Ashland: Exactly. I have talked to many individuals who had a psychotic break in the middle of their residency because of these human rights violations. They’re young often and don’t realize that these experiences can result in a permanent mental health issue. It’s imperative that you speak up, that you take care of your basic human needs, which include access to food, water, ability to go to the bathroom and relieve yourself when your bladder needs to be emptied or your bowels. That you are able to sleep uninterrupted and disrupted for . . .

Pamela Wible: Not in a state of hypervigilance.

Sydney Ashland: Exactly.

Pamela Wible: There have been people who’ve died by suicide because they couldn’t even when having an opportunity to sleep, they’re in such a hypervigilant, fragmented state from all this fight or flight, right?

Sydney Ashland: Right.

Pamela Wible: They can’t even sleep when given the opportunity.

Sydney Ashland: I recently spoke to an OB/GYN who, when he was complaining about the number of on-call hours, was told, “Well, this night, you are only interrupted once.” But what there seem to be no empathy for was the fact that he laid awake all night waiting for the phone to ring, waiting for the beeper to go off and that is not a healthy state. That is an unhealthy state, one that cannot be sustained. It’s unsustainable.

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Pamela Wible: Yet it continues for years in residency.

Sydney Ashland: Yes.

Pamela Wible: Another example here.

“I did my internship in internal medicine and residency in neurology before laws existed to regulate resident hours, which are sadly not enforced and these people are then told to lie on their timecards. The law doesn’t necessarily help. My first two years were extremely brutal working a 110 to a 120 hours per week.”

Just as an aside, I want to mention there’s 168 hours in a week so that would leave … If they were to sleep every moment outside of the. . .

Sydney Ashland: 48 hours.

Pamela Wible: 48 hours for sleep and seven days, but come on, they have to drive home, eat dinner, go to the bathroom. Yeah. Okay. Up to 40 hours straight this person worked.

“I got to witness colleagues collapse unconscious in the hallway during rounds and I recall once falling asleep in the bed of an elderly comatose woman while trying to start an IV on her in the wee hours of the morning.”

These stories are not uncommon. This is not like some weird guy just . . .

Sydney Ashland: In fact, truth be told, there are individuals who perpetuate this who find this amusing, who have some dark sense of humor and will laugh at some of the stories. I’ve been witnessed to that and it’s not okay. It’s not funny. It’s not humorous. It’s not a rite of passage. I will say that again.

Pamela Wible: It’s not safe for patients. It’s not safe for patients. It’s not safe for any human being. Again, let’s please say this out loud, human rights violations. There is no other word that summarizes what this is so well as human rights violations.

Sydney Ashland: Yes. Exactly.

Pamela Wible: You were talking about the ADLs, so activities of daily living. I don’t know, if you want to say.

Sydney Ashland: We just cease to be human when we’re treated as if we’re not human. When we’re treated inhumanely, something inside of us switches off and we become automatons. We objectify ourselves and we objectify others because we can no longer feel our embodied self. We cease to even recognize our basic needs, so we don’t notice that we’re hungry or sleepy or have to pee or need to cry.

I’ve had physician after physician almost actually across the board, physicians who laugh at the idea that they no longer really can tell when they have to go to the bathroom or they’re so used to being hungry that they just turned it off. They don’t even notice it anymore. We feel numb. We feel disconnected. We feel disembodied and that’s what this disruption of our basic human needs, the ADLs that we all need in order to be categorized as human, are disrupted by these horrible human rights violations.

Pamela Wible: One other way of looking at that is the … I’m sure many of you are familiar with Maslow’s hierarchy of needs. Basically, seven years of medical training plus you’re thrown to the very bottom rung, if not below the bottom rung of Maslow’s hierarchy of needs. These are needs that human beings have to be happy and successful and healthy in life and you are sort of sub-rung one. This is not normal. This is not burnout either.

Sydney Ashland: No.

Pamela Wible: Burnout is a bullshit term.

Sydney Ashland: All the resiliency in the world is not going to allow you to deprive yourself of your basic human needs. It’s impossible.

Pamela Wible: That’s why the woman collapsed. The colleague collapsed in the hallway. You cannot survive when your pH goes out of range. You actually have to submit to the same physiologic needs that your patients have, which is why you’re collapsing, getting into car accidents and unable to continue working in this way. Of course, the downwind effects on your marriage and parenting and sex life and everything else.

Sydney Ashland: Right. Well, those become almost mute because it’s all about survival. There’s nothing about thriving. It’s all about survival.

Pamela Wible: This whole idea that, “Oh, let me hang on. It will just get better. You carry this with you for the rest.” Unless you’re in therapy … I’ve spent more in therapy than I have in medical school tuition to overcome some of my trauma. Unless you have dealt with this upfront with a therapist, you’re probably still carrying this around with you 20, 30, 40 years later into retirement.

Sydney Ashland: Yes.

Pamela Wible: That’s so sad.

Sydney Ashland: Sad truth.

Pamela Wible: Number three is vicarious trauma. This is something that I think every emergency physician and neonatologist and surgeon have probably experienced. I consider myself fortunate in family medicine. I don’t feel that I’ve had much of this. However being on the phone with a neonatology fellow recently who called me wondering if it was normal for her to have like panic attacks and start crying in the middle of the night, when she . . . I asked her kind of what she’s doing. Well she’s flying around in a helicopter, picking up half-dead babies, preemies all over the county and apparently is the only one responsible at night for like 40 highly sick NICU patients. I think that would cause anyone on the planet to be having panic attacks. What do you think?

Sydney Ashland: Right. Well, I think what it creates often is emotional flooding and triggers. When you are experiencing vicarious trauma, you’re in a high stress medical environment. You find yourself overwhelmed by some triggering event. Someone looks like, talks like or presents with the same symptoms as someone that you lost in a traumatic event or someone that, in the heat of the moment, you have may have made a mistake. A medical mistake.

PTSD Brain

You find yourself suddenly triggered. You feel disembodied. You can’t really tell whether you’re in a current situation or in the past situation. It’s so similar. It creates this emotional flooding of overwhelm, grief, sorrow, fear, phobia. You can no longer really remember the steps of what you need to to do next. It interferes with your memory. You can no longer remember how to intubate the patient or are insecure doing so. You can’t figure out how to put in a central line and you’re embarrassed and confused because you’ve done it a million times, but you are suffering from this vicarious trauma. You are struggling with fight-or-flight symptoms because you’re confused. You don’t know what to do. Severe detachment, sometimes depersonalization happens, and then you’re in this dissociative state that makes it impossible for you to remain present.

These people are at risk of being accused of a patient abandonment because often they need to take a break. Ask someone else for help. They flee the emergency room. They asked someone else to step in during surgery or during the ortho procedure and it can happen to anyone. It isn’t limited to those specialties.

Almost anyone working in a traumatic medical environment is at risk. It’s important for you to recognize, “This is trauma. I’m feeling stressed. I may even be a little bit shocky. Can I feel my body? Am I in a cold sweat? Do I feel triggered?” Notice that I’m either numb or so flooded by these strong emotions that all I can think to do is fight or flee.

Pamela Wible: Yeah, this brings up another call that I had with an emergency room doctor who actually, she finished her residency. She’s highly skilled like level one ER type doc who always puts herself in the highest acuity emergency situations because she doesn’t want to lose her skills. She ends up having to help so many people from so many car accidents, many I’m sure have died or have been completely mangled. Now she is unable to drive a car herself without having panic attacks. She ended up, last year, spending $13,000 on Uber rides.

Sydney Ashland: Oh my goodness. $13,000, that’s just unbelievable.

Pamela Wible: Yeah. Would she be doing this if she was a real estate agent? How would she be if she was working at Walmart? This would not be an issue, right? This is occupationally-induced PTSD, vicarious trauma and there’s no help. Where does she go? If she asked for help, she get locked up into a PHP. She can’t go to a psychiatrist. This is why these people are crying to me on the phone at midnight wondering if they’re normal. You’re normal. It’s a normal reaction if you’ve seen that much trauma to have panic attacks. Is that not normal?

PTSD-Trauma

Sydney Ashland: Right, that is totally true. And, I’ve seen it happened to people who feel like overall they’re quite well-adjusted. They have a happy marriage. They have children at home. They’ve been working in the ED or in surgery for years and years and years and years, and they’re unaware of the accumulative toll that this level of trauma can have on a person.

They suddenly find themselves no longer next to the patient in the ED but inside a broom closet trying to figure out what they’re going to do next. Shaking, crying, feeling totally out of control, feeling panic and like there’s some sense of impending doom for them, not just for the patient and they don’t know how to get out of it.

I think the most important thing for anyone listening to this who hears and recognizes them self in these words and these stories is that trauma over long periods of time does take its toll. That if you are someone who has worked in these high stress situations, you really need to be prepared and have support so that these triggers don’t get activated.

You can have triggers the don’t get activated and that’s an okay thing. Many of us walk around having experienced trauma in our lives and just know how to take care of ourselves in a way that we don’t end up in a triggered or emotionally flooded state.

Pamela Wible: One thing that I want to bring up as a result of vicarious trauma and having this delayed gratification being in school till your mid 30s. By the time you get out and you realize you’re just not paying off your hundreds of thousands of dollars of loans, you finally have your first job, you’re in such a terrible mental health state that it makes it really impossible. Both these examples, the neonatology fellow and the emergency department physician. They’re both women in their mid 30s who have their eggs frozen, haven’t been able to date, still want to have families of their own. Do you see the obstacles between this? This one, how do they even go on a date? They can’t even talk about normal things like going to the movies and the weather. All they can think about is dead premature babies and mangled people in car accidents. Right?

Sydney Ashland: Right.

Pamela Wible: This does not make it easy to date.

Sydney Ashland: No. What ends up happening is you can find yourself at 45 or 48 wondering where the time went and feeling resentful and angry.

Pamela Wible: At patients.

Sydney Ashland: At patients and beginning to objectify colleagues because of what’s happened to you. We’ll talk more about what can happen when you displace your emotions later.

Pamela Wible: Number four, losing colleagues to suicide. This is a huge problem in medical education. I think, right now, I have a list of close to 700 completed suicides among medical students, residents, physicians and by and large, besides the fact that they’ve just lost somebody, which is absolutely traumatizing in and of itself. Your cubicle mate, your surgeon you operate with is no longer at work, right?

Sydney Ashland: Right.

Pamela Wible: You have not been offered by the hospital, by your residency program, by your medical school any way to properly grieve from this. The answer is not, “Let’s take a moment of silence before our next test.” That’s not going to help. A moment of silence is not enough. Also lying, hiding this. Medical institutions saying, “Sorry, somebody passed away suddenly this weekend and it’s your . . .”

Sydney Ashland: Yes, at 24 years of age.

Pamela Wible: At 24 years old with no answer and then the family calling it an aneurysm when it was a gun shot wound. This stuff really upsets me because, of course, we’ve already lost the person, which is upsetting in and of itself, but we’re continuing to wound and rewound everyone every day that we don’t deal with this upfront.

I want to know why we have allowed our medical institutions that apparently are here for science and human health to perpetrate these crimes against their staff for so long. It’s very upsetting. I’m going to read a letter I received from Bruce, an anesthesiologist who writes … By the way, there are so many anesthesiologists found dead in hospital call rooms and closets. I think if you Google doctor found dead in hospital, it’s probably all male anesthesiologists found in …

Sydney Ashland: Well, it’s a high rate for sure.

Pamela Wible: They say no foul play. How is this normal? This is certainly not normal. Anyway.

“In anesthesiology, it seems we have a higher percentage of death by suicide than other medical specialties. My colleague took his own life over a year ago. I was basically okay until then, but it’s how everyone reacted that really got to me, the show must go on.

We diverted patients the first night probably because the ER had to see Joe when he came in. The next day, all of us were back at work in the operating room. There was no time to grieve and we and the department were so stunned. We didn’t know what we needed and what to ask for. It felt like abuse not to honor him or his colleagues with some rescheduling of operations. I will never be the same. I no longer see medicine as a force for good. It seems like it is a way for other people to make money off our talent, intelligence, education or determination.

He was my friend.”

Sydney Ashland: That’s so sad. So, so sad. Even in the battlefield, soldiers pause for their comrades. They honor their comrades. They talk about it. They share their stories.

Pamela Wible: They go back home and talk to their families.

Sydney Ashland: Right. I think that losing a colleague to suicide so often ends up in misdirected and displaced feelings because of the very thing you’re talking about, which is we’re not given any time to grieve and there’s this secrecy.

Pamela Wible: And lies.

Sydney Ashland: Yes. Well, it’s still taboo to really talk about suicide. We’re unable to really feel our grief or our rage. We feel either like we have been abandoned by the person who suicided, or we feel like we abandoned them because we start reviewing and reflecting and saying, “If only I could have, I should have. If now I could, I would.”

We are immobilized and wrapped up in this tangle of feelings that we don’t have anyone to help us process. We don’t want to talk about it in our society. We’re not talking about it in the hospital or at a medical school. We’re at risk of misdirecting and subverting those feelings that are very real that need to be talked about, that need to be brought out into the light of day.

We start to self medicate. Perhaps we start an emotional or physical affair. We have feelings of being alone and overwhelmed. We isolate because we can’t share what we’re feeling with anyone because it’s not okay. “It’s supposed to be a secret and if I don’t harbor this secret or share it with someone then I’m somehow betraying the person who took their life or betraying their family.”

It becomes this unbelievable weight that is wrapped in secrecy. We all know that secrets are absolutely some of the most toxic forms of manipulation and control that can be used against another person. It’s extremely important to find a bereavement group. It doesn’t matter if it’s at hospice, if it’s somewhere where you’re not sure you can talk about suicide.

Find a place where you can talk, where you can process, where someone is willing to hear your experience, your story and where there’s enough room and space for your feelings so that you’re not at risk of misdirecting or displacing them on a colleague, a friend or somebody at home.

Pamela Wible: Something that really upsets me from a recent call with a resident who told me that she lost a co-resident in his third year of pediatrics residency. He shot himself in the head after he was reprimanded for something that he really didn’t do anything wrong. It was some minor thing, but literally he was going to be fired. He was fired from his residency. Like with a months to go, there’s a number of cases by the way of suicides of residents who are fired or bullied or just pushed over the edge within months of graduating. They feel like everything they’ve worked for their whole life is gone, so they basically take themselves out.

Now, the residents who survived this know the truth of what happened because, come on, there’s only six or seven residents. You know if one of your co-residents is being abused. What happened in this case is that one of the residents spoke up, wanting to at least know the truth or have some processing. Not just the grieving related to they lost their colleague, but the fact that their own residency was probably responsible or somebody in the residency for that person choosing to die that way.

What happens is then that co-resident who survives gets thrown under the bus, forced to go see a psychiatrist. Labeled and written up as unprofessional for questioning the death.

Sydney Ashland: Well, and then they’re left with survivor guilt, because why did this person not survived and why am I surviving? Often, the staff at the medical school or in the residency program are unequipped themselves to deal with this. They feel their own guilt and shame.

Because they don’t have a place to process it, they treat their students and residents in kind by hushing it, trying to send it underground and it never works for anybody. I have also heard of attendings and professors who have been tortured by the student, the resident, the colleague who killed themselves. It’s a career-ender for them sometimes too.

Pamela Wible: I want to share something that I shared in Washington, DC during a keynote talk to some medical educators that run the osteopathic medical schools in the US. I gave this analogy. I wanted to share just … It’s called postvention, the reaction, what we do after a suicide, how we handle it as an educational institution. I compared medical student suicides with school shootings. Since 1980, we’ve lost 320 people in the United States to school shootings at the time I gave this talk.

Sydney Ashland: Yeah, that’s a much higher number now. Yes.

Pamela Wible: It was surprising how low it was really to me. Maybe it’s 350 or something. I gave this two years ago. I’m just saying in the scheme of things, we lose 300 to 400 per year of physicians. That doesn’t even include medical students. Nobody is even tracking these, which I can’t even believe we’re not tracking this.

Anyway, we’ve lost 320 people in the US to school shootings. That’s less than one year of the number of doctors and medical students that we’re losing to suicide. Look what they do for school shootings. They shut down the school. They let everyone go home. They put flowers on the doorstep of the school. They put teddy bears in the fence. They call in counselors from all over the place to come and help their students. Everyone goes to a local church and is holding candles. On national TV, people are crying and hugging and we don’t do anything for medical students or doctors that die by suicide. What do you think?

Sydney Ashland: Well, that’s so sobering and it’s so true. I think it’s because we have such a high level of discomfort. We have such a high level of guilt and feeling helpless and hopeless ourselves. The only way to fix this problem is by empowering others, empowering ourselves through our action so that we begin to speak up and speak out and no longer participate in the secrecy.

Pamela Wible: It’s so important just to, as simple as it sounds, tell the truth.

Sydney Ashland: Tell the truth. Be a truth teller.

Pamela Wible: Last on the list of five. I know we’re going on for a while but these are important and this is a conversation that needed to happen decades ago. The fifth issue is chronic, toxic workplace. I have been in many myself. I know of other people who feel chronically underappreciated as a physician, or over-regulated, or treated … Essentially, what it seems like to me as you take these brilliant, compassionate, highly motivated people, you put them through number one through four. They’re already sort of functioning on fumes, right?

Sydney Ashland: Right.

Pamela Wible: Then you put them into a terrible big-box clinic forced to see patients every five to seven minutes on an assembly line. They’re basically treated like these bad kindergartners, right?

Sydney Ashland: Right.

Pamela Wible: You have people with lesser education, lower IQ than you, herding you up, rounding you into your little cubicle and forcing you to stay there and work at an unsafe speed. What the heck?

Sydney Ashland: Right. I want to just identify how you can tell if you’re in a chronic toxic workplace. Number one, there’s an overabundant need to control, control processes, control people, control time. Secondly, there’s a lack of communication. People aren’t talking to each other. There is passive aggressive energy because people don’t talk to each other. They’re not expressing their feelings. They’re over controlled. They begin to act out in passive aggressive ways.

Then people begin to isolate and withdraw and stonewall. Then communication stops altogether. Those are just some of the attributes of a chronic toxic workplace that I hear about all the time that it’s over controlling, there’s a lack of communication, there’s passive aggressive energy and people begin to stonewall and withdraw, and it’s impossible.

You cannot work effectively and you certainly can’t be an effective healer in a chronic toxic workplace. You may experience fight or flight in this environment. You can’t decide whether you want to rage at your coworker or whether you want to flee the scene. I’ve talked to many, many people who have done one or the other or both. They rage and then they find themselves fleeing. The next thing you know, they’re accused of leaving the workplace without permission. They’re written up or they’re fired. Or they’re labeled as obstructionistic, or what’s the other word?

Pamela Wible: Disruptive.

Sydney Ashland: Disruptive physician.

Pamela Wible: Unprofessional.

Sydney Ashland: How could I have forgotten? I think it’s purposeful amnesia that I can’t remember that term disruptive physician because I get a call almost every day. “I’ve been accused of being a disruptive physician. I’m being threatened by disciplinary action either at the local clinic level, at the administrative level, at the hospital of somebody whistle blowing to insurance company over something that isn’t even true.” Or that the most ultimate, which is reporting you to the board.

It’s incredibly frustrating to deal with all of these victims of chronic toxic workplace environments. It’s innumerable. I mean there are thousands that are suffering in that environment. What I want to say to you is there are strategies that you can employ to either shift how you show up at work so that you are impacted less or strategies that can help you get out of that workplace environment.

If you are designed to be an employee, if that’s who you really want to be, then to at least be able to interview and find a more compatible work environment. If you are someone who is better suited to being a business owner or entrepreneur, then there are definitely very, very empowering strategies that both Pamela and I can share with you to get you out of that toxic workplace.

Pamela Wible: One way that I describe this chronic toxic workplace situation is PTSD by a million paper cuts.

Sydney Ashland: That’s a very good description. You’re bleeding out because you’ve had a million paper cuts. People keep walking by and saying, “What? It’s not so bad. It’s just a paper cut.” It takes its toll.

Pamela Wible: One thing I want to say as well is that no matter how beautiful your house is, what a wonderful car you drive, this is not going to help you recover from this. There’s this feeling at least from non physician members of our society. They look at physicians and think, “Well, what do you have to be complaining about? You’ve got such a beautiful house. Your kids are in college. You’ve got a trophy spouse, a perfect car.” This does not help any of these five elements get better. You absolutely need to talk to somebody.

Sydney Ashland: Right. So often people talk to me in hushed tones and really think it’s something about them. They have come to internalize all of these experiences and have begun to believe that there’s something wrong with me. Everyone else seems to be doing okay. It’s me that is the disruptor. It’s me that is the problem and I’m here to tell you that it is not you.

That you are someone who has suffered, who has been exposed to inordinate stress, trauma and now find yourself in a chronically toxic workplace. It is not you. There are answers and that’s why I get so excited, Pamela, with what we’re doing in connecting with physicians at these large retreats. Those small one-on-one groups that we meet with. The private retreats where we have 10 to 15 doctors and we can do very individualized strategy sessions.

Physician Retreat - Join Us!

For private invitation-only retreats, contact Dr. Wible here.

I’m so excited about what it is we do and that’s what I focus on, because otherwise, I think I might be at risk of feeling overwhelmed. Of feeling like I can’t do enough, quickly enough to really impact the problem. Instead, I focus on what I’m able to do in my little small piece of the world with you. What I see every month, every day actually in my Skype sessions and phone calls as I witnessed people who choose life, who choose the very courageous act of returning to their original dream and to really …

Pamela Wible: That they wrote on their personal statement on the way into medical school.

Sydney Ashland: Absolutely.

Pamela Wible: You can still do that.

Sydney Ashland: Yes. Yes, yes, yes. It is not too late. You are not too damaged. You can heal from what you have experienced and you can begin to actually experience what it’s like to be human. What it’s like to be human and feel joy and feel gratification. Feel a sense of reward and purpose. Because let me tell you, that’s what Pamela and I wake up feeling everyday and we love to share it with anybody who is interested in embracing that for themselves.

Pamela Wible: How can people reach you, Sydney?

Sydney Ashland: Reach me at sydneyashland@gmail.com or sydneyashland.com. I also have a Facebook page, so you can find me. I would love to speak with you and help you figure out what your next steps are in either joining us at one of our retreats or doing one-on-one work with Pamela. If you’re interested in doing some high-end professional work and business strategizing or to work with me and removing some of the emotional, psychological, spiritual blocks that end up happening as a result of sustained trauma and stress.

Pamela Wible: I think you make yourself very available. You even have emergency sessions for people, right?

Sydney Ashland: I do. Same day. Please reach out. There is help. The other thing that is so fantastic about our work is that we have now a whole network of physicians. How many graduates do we have now?

Pamela Wible: I think close to 500 have been through these retreats over the years.

Sydney Ashland: We have mentorship programs. We have special Facebook groups where people can support each other and sharing their stories initially and beginning to believe that they can return to the truth of who they are and then in strategizing the best way to extricate yourself from this difficult situation and move forward with joy.

Pamela Wible: It’s awesome. I really love this work and I really love the balance that we have because you handle more of the emotional, intuitive, psychological piece so well. I love to do that myself, but I think that’s really your strong suit. I think I’m really best suited with high-level business strategy for medical professionals who really want to take their practice to the next level and do something quite innovative, entrepreneurial, change the workplace, change their hospital system. I’m very happy to help anyone.

Sydney Ashland: To mentor the leaders of tomorrow.

Pamela Wible: Of course. Right. Yes. I’ve worked with hospitals CEO and led executive teams of hospitals, even out-of-state, from my pajamas in Oregon, which is really fun. Before we recap and end here, I just wanted to touch base with you on why you think some people don’t reach out for help. I really get concerned.

For every one woman we lose in medicine to suicide, we lose seven men. These retreats that I lead are often skewed towards more female physicians. I love working with women, but I’m very concerned about the men and the physicians out there that are resistant to asking for help. What do you recommend?

Sydney Ashland: Well, I think the top reason people don’t reach out for help is fear that if they reach out for help, it will be reported, there will be a track record of inability to cope, and they’re in fear. What I want to reassure you is that you should reach out for help. That we are all about helping you move into the next in an empowered way.

Let go of that fear. I think also, our lives become very, very complex. We may know that we had a difficult childhood, but that difficult childhood that we transcended and then took our genius into medical school somehow may have left us at a disadvantage. We believe that. Then we somehow feel like we are less than. That we made it through medical school, fully hoping to transcend that experience and we never feel like we quite get there. Then we get married or we have a partner and we start to have kids.

Our lives become more complex and before we know it, we feel like we’ve made a mess of it all. That it began way back when. What I’m here to tell you is there is healing, that you are brilliant, that your call to action and your calling in the world matters. That it’s not too late. It is never too late.

Pamela Wible: Beautiful. Yeah. One other thing I want to say about asking for help. I’ve run a suicide hotline for physicians since the fall of 2012 and I have never turned anyone in to a PHP. I’ve never called 911 on anyone. I absolutely hold your competence as sacred and I want you to reach out to get help somewhere. It can be me, it can be Sydney, but one caveat I want to give is don’t ask for help of somebody else who’s drowning and spiraling down the bath tub with you, because that’s often what happens is medical students may reach out for help with another medical student who’s also suicidal and then you’ve got two suicidal medical students, right?

Sydney Ashland: Exactly.

Pamela Wible: Please reach out to somebody who is more resourced than you.

Sydney Ashland: It can seem pretty bleak. I have worked with people who have had addiction issues and who have even lost for a time or had their medical license suspended. Who have then recovered and have moved forward to recover not only physically, emotionally but had their medical license reinstated and who are now working with other people who are in recovery or other people who have mental health issues. It’s truly never too late.

Pamela Wible: There is a place for everyone and nothing happens by accident. I think we’re all wounded healers. That’s another thing I want to mention. How many people that become physicians do you think are not impacted by one of those five things? I feel like everyone must be impacted by something.

Sydney Ashland: Certainly.

Pamela Wible: That we’ve mentioned in their training. I don’t think anyone gets out of medical training or medical practice unscathed with no scars. Right?

Sydney Ashland: Right.

Pamela Wible: Please do recognize in yourself what you need help with and ask for help whether it’s your pastor or somebody, or us, or a colleague. All right, Sydney. Thank you.

Sydney Ashland: Thank you Pamela. Thank you. This has been great.

Attend our January Retreat on the spectacular Oregon coast.

January Retreat

~ ~ ~

Pamela Wible, M.D., is a solo family physician in private practice. She leads popular retreats for physicians and medical students (all health professionals welcome).  Dr. Wible also offers monthly retreats with Sydney Ashland. Inquire here for next retreat.

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12 comments on “Physician PTSD—Are you a victim?
  1. Danie Botha says:

    Pamela & Sydney,

    Thank you for a (very) thorough overview of this dilemma facing physicians and our health care delivery systems collectively—PTSD & depression, sprouting to a large extent from an abusive medical system—whether in the US, Canada, UK, Europe or Australia.
    In essence, we are caught up in this broken reality of (what a misnomer) “healthcare” due to the fact we (MDs, Licensing bodies, HMOs, Hospitals, Health Authorities, Health ministries etc) have long discontinued practicing ETHICAL MEDICINE.
    We don’t even teach ethical medicine.
    Oh, we talk about it. It sounds nice and honorable.
    Medicine has become a business.
    I’m not talking about getting paid at the end of each month.
    Chemotherapy, to name but one is a MULTIBILLION dollar business & industry.
    Also, we don’t provide “healthcare,” we provide “sick care.”

    I have two requests, Pamela (& Sydney):
    1. Can you make a shorter version of this article? More people will read it.
    2. How do we “FIX” the problem?

    For many of us, due to the nature of our training & practice, cannot step away on our own and practice independently. (e.g Anesthesiologists)

    But, I will keep spreading the word, and keep practicing ETHICAL medicine.

    Thanks for sharing, Pamela & Sydney!

  2. Dawn Matejka says:

    Thank you for your efforts in addressing this issue.
    It takes COURAGE to humble oneself and ask for help.
    The person who reaches out for and receives help becomes a stronger and more authentic caregiver.
    This is the message we need to hear to further remove the stigma of seeing a therapist or attending a support group.
    I would rather be cared for by physicians or nurses/other ancillary medical personnel who have received help with their own struggles in life then someone who tries to manage it alone.
    I have found it very helpful ti listen to the Trauma series offered often by NICBM.
    The Webinars, given by world renown leaders in the field of psychology/psychiatry have given me a wealth of information on PTSD…the bidy’s response to Trauma and how to recognize its affects and better manage the affects of Trauma (which includes vicarious Trauma and bullying). It was very helpful, both for my patients and for myself. ( CEUs are offered.)
    The contact person for these excellent offerings is Ruth Buczynski.

    I will never regret “seeking help”.

  3. One Almost Doctor says:

    Dear Dr. Wible,

    Thank you so much for your writing.

    I was raised by people who are very in touch with their feelings so I have weathered medical education well. I developed rituals when I get home to shake off the stresses of the day. I am so compartmentalized that it borders on multiple personality disorder! I read your articles with sympathy but feel bad speaking up as I have never been subject to much of the maltreatment you describe. On the contrary, most of the people I am around on a daily basis are an inspiration! But the system is malignant and toxic, and I didn’t realize how badly I was affected until I was staring at your Physician PTSD Pop Quiz and crying on a rare day off.

    A. Teaching by terror – YES and even when I think they mean well. Maybe I have Stockholm Syndrome but… I don’t think anyone wants it to be this way. However, I’ve seen students and residents harshly disciplined for minor issues, so I am a silent little mouse and terrified to accidentally step out of line. I have panic attacks about it. I have seen people mocked for asking for minor accommodations that honestly affect no one, so I would never dare. In my first week of medical school, I was randomly assigned to an anatomy cadaver that died of the same rare disease as one of my parents. I was afraid to ask to be moved as my professors so emphasized that being tough is part of being a good physician. I stared at the physical effects of this disease from the inside out for months and had nightmares about my dead, naked parent on that table for a year afterward. Somehow that is nothing much compared to the daily trauma of being given conflicting instructions and being terrified I will get in trouble no matter what I do. After all, it wouldn’t be the first time.

    B. Human rights violations – Due to a large emergency expense, I couldn’t afford to buy food at the hospital on an inpatient internal medicine rotation. I also was given no place to store anything so I would fill my pockets with dollar store granola bars and pray they kept my stomach from growling. One day I forgot them and got so hungry after a long day that I “stole” cold leftover rice from a meal left for attendings in the physician’s lounge. I was so afraid I would be caught and have to explain. I lost almost ten pounds off an already small frame during that rotation.

    C. Vicarious trauma – In many ways this is unavoidable, just the nature of medicine, but I wish we had a space where we could show our feelings to others. No one outside the field can understand but no one inside the field wants to debrief. Or perhaps they do and we are all just afraid to ask each other.

    D. Suicide of a colleague – a physician near me killed themself recently and it was hushed up. People are uncomfortable if you even mention them. We weren’t close but it’s a lot to process.

    E. Chronic toxic workplace – So many examples but this one still bothers me: I had a preceptor in medical school who pressured me to pray with him. We are not the same religion. When I finally told him I was not the same religion, he gave me a written testimony of how his religion saved him from a sex addiction. With a LOT of details that made it very difficult to work with him. It was brought up repeatedly for the rest of my rotation. Even worse, he also made fun of transgender people in front of me, laughed with his staff at a patient and made derogatory statements. I cried angry tears on the way home that day and felt ashamed that I didn’t speak up for what is right. What is wrong with me? Why didn’t I stand up for that patient? I still am so angry at myself because I should have done what was right. My patients need people like me to be good allies and I failed. I was even afraid to tell my school or complain, as I didn’t want my grade or transcript affected.

    I don’t know when a strong outspoken woman became such a coward. I revised this email repeatedly to remove identifying information even though that means leaving out the real horrors. I made a dummy email so you won’t know my school and residency because I am just too afraid. No one can ever know any of this. I might get in trouble. I might be viewed as a troublemaker or unprofessional. I feel guilty when I have done no wrong. That’s the most malignant part of this system, being shamed into silence.

    Anyway, thank you. I am a believer in the occasional good cry and I needed this one. We’ll make it better together, and this is the first step.

    • Pamela Wible MD says:

      Wow. I’m so glad you made it through the podcast & blog and that you found it so therapeutic. We all need a good cry in medicine. Please do reach out to me anytime (confidentially here): http://www.idealmedicalcare.org/blog/contact/ and I would be very happy to talk to you.

    • You are NOT a coward. You are very wisely self-protecting during the last leg of your journey in residency. I’m sorry you are afraid and I understand that you need to do what you can to stay safe. It is important that you allow yourself the secret place deep inside where you know the truth about yourself and your situation. Guard that place. Remind yourself daily that you are doing what you need to to reach the end goal. Someday soon you will be free to practice medicine the way you see fit and Pamela and I will still be here to help you realize that dream. Thank you for writing.

  4. Dr. Jacob R. Raitt says:

    Way too long to read it all.

    Remember that the body of knowledge turns over every 10 years. Education must keep up. Take no longer than two years to teach the basics in medicine, and then show different pathways to be taken by those who so desire.

    • Pamela Wible MD says:

      Yep Jacob. Modern teaching method needed. We don’t have to terrorize the gifted to help them learn. Counterproductive. Learning should be a joy if done properly.

  5. Surender Juneja says:

    Thank you very much for the wealth of information which provides some insight into the unfortunate event which has directly or indirectly touched the lives of many of us.
    Apart from the suicides, significant psychological issues are frequent among medicos.
    One aspect from personal experience is that the field of medicine is so competitive, we spend every spare minute in our life from school age getting into medical college & after that enhancing our career prospects in a super-competitive field, with the resultant lack of time for socialisation which is the distraction/relief we all need to keep sane/balanced. As a result we have limited coping mechanisms when things go wrong. It happens to all humans, however, we the ill-prepared lot can not deal with them properly i.e. there is lack of resilience. Also because a majority of medicos are high achievers, they handle the imperfections of life less well than general population.
    Somehow we need to make ourselves more resilient.

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