Preventing “Happy” Doctor Suicides →

In this closing keynote at Psych Congress 2019, Dr. Wible reveals the results of her 7-year investigation into more than 1,300 doctor suicides—and shares simple solutions to the suicide epidemic in an uplifting, life-changing, and surprisingly entertaining session. Warning: Though content is tragic, audience bursts into laughter more than 20 times during the first few faculty disclosure slides.

Dr. Rakesh Jain: This next topic of conversation we will have is obviously of great importance to you and me, otherwise you wouldn’t be here, that’s “Healing our Healers: Preventing Physician Suicide” and, you know, psychiatry is all about storytelling, is it not? That’s why we came into this field, so can I tell you a quick story about a 27-year-old intern in internal medicine about three decades ago? Would you be okay if I told you a quick story about this intern?

So a 27-year-old, first-year intern, three or four months into his residency was struck down by his second episode of depression, didn’t quite know what was going on with him, but somehow found a family physician, knew something wasn’t quite right. Went to see him, got put on imipramine, which was at that time, this was before there was an SSRI, but no therapy at that time, no understanding. No one actually asked him about anything, about suicidal ideas. Things sadly did not go well for this intern and he started really slipping into his depression and one night actually put out all his imipramine on the bed to decide what would be a fatal dose, how quickly it would work. Just heartbroken. That intern was me.

This is from a long time ago, 32 years ago, and from literally nowhere, for reasons I didn’t even know, it is a family issue. I was struck hard. I think it was because of a failing marriage and new stress. I went in next morning to my program director, handed him my beeper (at the time there were beepers), handed him my ID and I was three months into my internship. I said, “I quit.” I didn’t tell him why I wanted to quit, which was to end my life. I was wanting him to know that I was good enough, that I was giving him notice.

He though saw something. He made me sit down. He made me talk and I talked and I talked and I talked and he took me to the next door office, which was a wonderful psychiatrist who for the rest of my life, I will be forever grateful, and she took me under her care and talked about suicide for the first time. Things were, however, rough. I went back to work, she put me on new meds. They seemed to help work. I called her at 8:00 in the evening. This is to tell you how grateful I am to you—psychiatry and psychotherapy. This is not a sob story. This is actually an optimism story.

I was crying my eyes out. It was 8:00 in the evening. I was on call. She drove over to the hospital, asked me to check into a hospital. Things were bad. I wasn’t psychotic, but I wasn’t that far from it. Then she said, “Okay, we’ll meet in the morning, we’ll decide.” What I didn’t realize is she was writing up the paperwork to commit me. Next morning, we met 8:00. I was still on call, so I just walked in my fatigue and I don’t know what the matter was but I was a little more optimistic. I think it was the human connection with her. To know someone who cared that deeply was profoundly helpful.

She did not commit me. I actually, by the way, didn’t find out that I was to be committed that morning at 9:00. I didn’t find that out until years later, but things turned around. But what turned it around was actually this profession. It was psychiatry. It was psychology. It was their desire to heal the healer. My gratitude to psychiatry is never ending. So, you guys, you not only help your patients, we often help each other.

So we’ve been talking about suicide very openly at this conference. It actually has come to visit us. I am someone who’s had lived experience with it myself. So we wanted to have a real expert come talk to us and we found Dr. Pamela Wible, who will be here in a minute, and she has a very wonderful resume that I would like to read to you, but at the end of the day, what she’s going to tell us is her experiences in helping other physicians recover.

Our risk is very high, really it’s high. Male, female, doesn’t matter. Nurses, very high. Nurse practitioners, most likely, MDs, psychiatry is high so we have a real expert. Sadly there’s a lot of me out there in psychiatry, in medicine, and we need to heal the healers.

Dr. Pamela Wible is a family physician born into a family of physicians who had the great insight to tell her not to go into medicine. She had the great desire to completely ignore them and come into the field and she got fed up with assembly-line medicine. She has had town hall meetings where she invited the citizens to help create their ideal clinic. Wow! Ask the customer what they want? Pretty weird idea.

Since 2005, she has had an innovative model that sparked a populist movement that has inspired Americans to create what are now called ideal clinics worldwide. She’s helped more than 500 physicians and clinician launch their ideal clinics. I’m assuming you’ll talk some about that, Pam.

But here’s why she’s here—when she’s not liberating doctors in this way or treating her own patients, she devotes her time to medical student and physician suicide prevention. She has investigated more than 1,300 doctor suicides and her extensive database and suicide registry reveals high-risk specialties and solutions. We are a high risk specialty by the way.

Dr. Wible runs a free doctor suicide hotline and has helped countless medical students and physicians, and I’m assuming other specialists, heal from anxiety, depression, PTSD and suicidal thoughts. Named 2015 Woman Leader in Medicine, Dr. Wible’s pioneering work has been featured on most major news outlets, The Washington Post, CNN, ABC, CBS, and NPR. She has delivered two truly outstanding TED Talks. I’ve heard both of them, watched both of them, and is a subject of a new documentary Do No Harm, a film that exposes the silent epidemic of physician suicide.

Think we made the right selection? We did. Let’s talk about “Healing our Healers: Preventing Physician Suicide.” Pamela, please come over to the stage.

Dr. Pamela Wible: Wow! This is amazing. You all are the survivors, the ultimate survivors of a week-long conference. Give yourselves a hand. I would also like to thank Dr. Rakesh Jain and thank this entire team of Psych Congress for putting this amazing event on. I’ve met some of the most incredibly brilliant people on the cutting edge of mental health and psychiatry and so I would like us to please give them a round of applause.

View rather hilarious full disclosure video above on full screen for full impact.

Full disclosure: I am not a psychiatrist. I want to make that clear. Some people think I’m a psychiatrist because I’ve devoted most of my life to mental health care. My mom is a psychiatrist, though. Has anyone in here had the great fortune to have a psychiatrist as a parent? One. Who has had the great fortune of having physician parents, one or both physician parents? Wonderful. Both my parents were physicians as was shared earlier.

So literally, I had to be an expert in physician psychology to survive my childhood. What’s interesting, there’s only one person that might have had this shared lived experience with me—the gentleman in the front row who also had a psychiatrist as a parent. My mom, a psychiatrist, did this interesting thing (it only happens with psychiatrists, I don’t think any other children have had these experience) my bedtime stories came from psychiatric journals.

She was in residency when I was just really little, and you know these needy kids need so much of your time and she’s got so much of her time devoted to listening to her patients. You know, it just makes sense to multitask. Right? So she would read the psychiatric journals to me and every time she landed on one of those pharmaceutical ads, she would stop and she would tell me to analyze the woman’s face.

These are 1970s Valium ads. Anyone have the great privilege to see one of these? Usually like really freaked out housewives. Right? She had me staring at them and she would do what Dr. Rakesh Jain suggested we do at breakfast this morning, which is look at the face of the person on the screen and not just look at the face—figure out the mood of the patient. These are the questions my mom was asking me when I was like two. So I got really good at analyzing people’s faces, and to the point where in high school I’m on a city bus, and my boyfriend’s like, “Stop looking at people that way!” It really is disturbing to other people who weren’t used to analyzing people’s faces in public.

Yes, let’s see, a few other things I want to share. This is a very brief one-line faculty disclosure (on the slide above), I want to give you the FULL disclosure. You’ve heard about full disclosures? I’m an open book. I don’t want to hide anything. I want you to understand who I am, what I’m talking about, and we’re going to have a really interesting conversation here and by the way, there’s no Q&A after my talk, but I am devoted, after the wrap-up, there’s a 15-minute wrap up when I’m done but afterwards, I will stay in this room till the last person leaves, answering any and all questions that you have. If you have to run out in the middle of my talk, because your flight’s leaving, IdealMedicalCare.org is my website. I return every single email, every single phone call, so your question I guarantee will be answered whether it’s here with the group or later.

So the problem that happened for me is when I entered medical school, I loved every specialty. I loved it all, and so it was hard for me to pick what to do because I didn’t want to exclude any organ system, any gender, any age, and so I managed to fall into family medicine. I went to this wonderful residency that had a behavioral health track, because you might not know, but there’s sort of two types of family medicine residencies, the ones that are very procedure based. You know, they train you to do C-sections in Alaska, that sounds terrible, or you could do like behavioral health, which seems much safer and easier for somebody who’s had my training with my mom and the psych journals, so I chose that route.

That’s the first full disclosure. I have four that I want to disclose. The second one is that I am sort of one of these “change-the-world” type people. Like the big picture system thinker and I have been accused of being “too happy” and also grandiose. This is by other psychiatrists, you know, online and such, and I think it’s because I have this unrealistic optimism, according to some people, about solving a centuries’ long suicide crises. This has been going on since 1858, you’ll see in my slide when the first reports came out that physicians had a higher suicide rate than the general public.

I’m very optimistic, excessively optimistic, about solving this. Now that I have the data, which I’m going to share with you, I feel like we can actually solve this because this is a problem that unlike Ebola or something where we have to like create a new drug or create something, figure out the human genome. The problem with suicide is really that it’s been a secret. Suicide isn’t really the problem, the problem is the secrecy. Once the secrecy can stop, and the stigma ends, I absolutely believe that we have the brain power, just in this room to solve the physician suicide crisis, if we stop hiding it.

I’d like to know how many of you by a show of hands know of a physician or a medical student who has lost their life to suicide? So most people in the room, and how many of you by a show of hands would like to end this physician suicide epidemic? Everyone. Great. I’m going to show you how in three easy steps. It might seem too easy to believe, but I’m excessively optimistic that it will work.

The third, I’d like to give you a full financial disclosure about who I really am and how I earn money because I’ve been accused of making money from human suffering. Now most doctors make money from human suffering, that’s sort of the business we’re in. If you’re not making money from human suffering, raise your hand. No hands in the room. Thank you.

I wanted to just really share how I do this. For seven years I’ve been running a free suicide helpline for physicians, and I’ll tell you how this came about in a little bit, but how I do this is I actually have this amazing clinic designed by my patients and community. They wrote my job description for me so there’s no like invisible tug of war in the room, we all are aligned in our intentions and goals and so I’m over here in my family medicine clinic, you know, where I like to work in my cute little Eugene, Oregon neighborhood and I do like ingrown toenail procedures and Pap smears and rectal exams. What else do I get? Acne, you know all this bread-and-butter family medicine, and I make all this pile of money over here, right, that supports my humanitarian free stuff that I do with doctors over here.

Because I’ve never charged any medical students or doctors for anything, any help that I’ve given them and so I run this suicide helpline and because I’m late night West Coast person and there’s a lot of people freaking out at like 1:00 in the morning in New York City and they’re residents. They call me. They don’t feel safe to necessarily tell their colleagues in their hospital that they’re having a meltdown, but they’re like, “Maybe I’ll call Dr. Wible in the woods in Oregon,” and since I’m usually up at 2:00, 3:00 in the morning, I end up on the phone for a few hours with residents on the East Coast.

The interesting thing about this is so I might be on the phone anywhere from five minutes to two hours with some people. Sometimes they call from unknown numbers, and one woman called from an unknown number and all she did was sob on the phone with me the whole time. Never gave her name, I don’t know if she’s alive. I don’t know what happened to her, but I just kept talking because you can see, I can fill up 75 minutes pretty easily, and I was hoping that something I said might click, right, might help her.

What I do with people when they call me, some of them feel immediately better because they were able to share their story for the first time with a colleague, without feeling like they were going to be turned over to the medical board, or get in trouble or lose their job. Some people email me, and they say, “I feel better just writing this email to you. Don’t even worry about calling me back.”

Great, and some people do need to see a psychiatrist, so of course I refer them to a real psychiatrist, not a family doctor who lives in the woods in Oregon, dealing with ingrown toenails. I do the best I can with the knowledge that I have. I have a whole group of psychiatrists that I refer to. If anyone in here specializes or would like to specialize in treating your colleagues, please let me know. I would love to refer people to you because there are people in all different states who need help.

The lovely thing that has happened as you heard in the introduction, since I have on the side, sort of helped other physicians launch independent practices, many of those are also psychiatrists who’ve launched independent practices specializing in physicians. So now I have like all these wonderful people who I know very well to triage people, too. That’s sort of how I make money. I just want to be completely transparent. I’m not funded by a drug company. I’m not aligned with any organization. I think that makes people feel nervous.

“Wait, she’s not at Stanford. She’s not aligned with any institution.” She’s a free spirit just running a suicide hotline without any permission from anyone. So that probably makes people feel a little unnerved. Right? Okay, I want to share more.

Full disclosure: the last little piece I want to share is that I do have critics. There are people that absolutely disapprove of the fact that I am running a suicide helpline, that I am doing this research and that I’m an activist in preventing physician suicide and there’s sort of a group of haters online in closed groups where I’m not invited that like to like put vomiting emojis up when they see my name and all sorts of things like I don’t know, (and a lot of these sadly are female psychiatrists). Like this was leaked to me in the last 24 hours. Somebody sent me a whole screen shot of all these things like, “How could they have her at this conference?” and I just want to apologize to Dr. Rakesh and if you’ve been pulled into this or Psych Congress in any way, if I have marred your reputation, I am so sorry, but I’m going to do a good job here and hopefully you’ll learn something.

The other thing, I just want to say, there’s many things they’re critical about. In fact, I have a whole spreadsheet. My plea: don’t kill the messenger, listen to the message. I’m sorry I’m not a board-certified psychiatrist. I’m a family physician with a good heart. I’m a truthspeaker, like that’s the thing that’s probably most important to me. I’m just absolutely against censorship and so pro-truthspeaking, and I think that’s where the healing comes from, and this is by the way, not a choice for me. It’s like having brown eyes. It’s not a choice for me. I was born this way. Some people say, “Oh, this is courageous.” This is, have nothing to do with courage, bravery, this is like I have brown eyes, and I tell the truth and I can’t help it. That’s just who I am. I can’t lie.

Before I go to the next slide, I just would like to share with you that you have a choice. I didn’t have a choice. I have to tell the truth, that’s just who I am but you have a choice as audience members. You have a choice whether to believe what I’m saying. If you don’t like what I’m saying, you can leave. If you want to stay and clap, you could do that. If you want to email me later. I want to give you the choice to do whatever you need to do, because this is a difficult topic. I will try not to trigger you, but I am going to tell the truth.

A few more disclosures here, the most important one is that as is typical of my behavior, I have permission from the surviving members of these physicians’ families who died by suicide who I feature in this presentation to share their stories. In fact, many of them are honored that I’m celebrating their loved ones. Some of them have reached out to me and before I even knew they existed or lost the family they’ve read parts of my blogs at their family members’ memorials and funerals overseas.

I’m going to introduce you to a few people that are really interesting in here, but I want to start with some learning objectives. Today we’re going to review why physician suicide is a public health crisis. We’re going to identify highest-risk specialties, discuss, why doctors fear seeking mental health care, and I’m going to describe three very simple ways that we can all destigmatize physician mental illness.

Before I move on to the first slide of the presentation, I have a request. One of the things that others are so critical of me about is my support of nurse practitioners and other professionals in medicine and so I know many people here, there are psychiatrists, there are nurse practitioners. I met lovely psychiatric physician assistants and psychologists and my request is: can we please stop the turf war between health professionals so that we can work together? We have a public health crisis and people are dying.

If you can prevent a suicide I don’t care if you’re board certified, I don’t care if you’re a medical student. I really don’t care whether you have a diploma or not. I’m just please asking for you to honor and love one another and let’s truly work together as a team to stop the death, to stop the needless suffering, so thank you.

These are our brothers and sisters in medicine, we are brothers and sisters in medicine and nursing and we are family, like you often hear during this Psych Congress, they refer to us all as a family, and I want you to take that seriously. We are family.

Here’s one of our brothers. This is Ben Shaffer. He was the go-to orthopedic surgeon in DC. Medical director, team physician for professional sports’ teams, the National Ballet, Olympics. I mean this is a job I would not want. How many psychiatrists in here would want to be sitting on the front row of the Olympics and when somebody has an injury of their shoulder, and that’s how they earn their millions of dollars a year, who would want to do that surgery? That seems high risk.

This guy is just built for this. This guy was fabulous, fabulous guy. A kind, sweet, brilliant, sensitive soul, he could relate to anyone, loved helping people, and in fact, you could look at this beautiful man, they called him “Dr. Smiles,” such a happy guy. I want to show you, this is Ben Shaffer in high school, right. He was voted most likely to succeed. Now that has a double meaning now that is terrible, right, but look at him, just look at his face. Do what my mom did with me, when I was young, stare at this man’s face, this man is a beautiful person.

He was voted also in junior high or middle school most school spirit, had lifelong anxiety, covered up with a beautiful smile, look at that, and so here’s the situation we’re in. Now why does that happy doctor die by suicide? See this is the most confusing thing for people. Everyone, nurses, patients, they’re like, “Wait a minute, he was just joking with me yesterday. What do you mean he hung himself in his office?” “Wait, she just had a newborn baby and was so happy.” People don’t see this coming.

It’s because if what you see is the smile, you don’t see the pain, right? And so, here’s the situation, the backstory with him is that he had just had back surgery. He knew (as an orthopedist) he was going to recover from this, he was given a good prognosis, but at the time he was like dragging foot, he couldn’t exercise, which of course one of the things that helps you when you have mood issues, right? Unfortunately, he was weaned off anxiolytics two months before, and his psychiatrist just happened to retire during this whole time, so he was transferred to a new psychiatrist who told him he’d be on medications the rest of his life. Ofcourse, he’s seeing this new doc in his worst moment and the psychiatrist doesn’t really have the full picture and so the day prior to his suicide, he admitted he was suicidal with a plan, but he feared hospitalization due to the stigma and reputation.

If you’re a guy that is at the Olympics, treating all these professional sports players, you can’t risk damage to your reputation. He did not want to be committed or be hospitalized for suicide, right, and so this man made a decision to hang himself at home after dropping his son off at school. Look at what we lost here.

I mean how long does it take to become a brilliant orthopedic surgeon? I read his whole CV, it was like 74 pages, the guy has done amazing work and we lost him. This should be a never event, right? Should this be a never event?

Audience: Yeah.

Thank you. So here’s the shock and the aftermath. These are actual quotes from people who were shocked:

What a great surgeon. What a great sense of humor. This guy made this child laugh before he went in for surgery. So patients are very confused.

I think that’s why this is so hard to comprehend. So there’s this other group of people that we don’t think about very much who are very adversely affected by this, which are patients. Now the research shows, potentially, that maybe we lose 400 doctors a year to suicide (researchers believe that number is an underestimate). It’s probably more because we’re putting a whole bunch of these suicides in the “accidental overdose” category, which I have a huge problem with. Let me explain.

A 100% accidental overdose is a toddler on the floor in a bathroom, playing with pink pills. That’s an accidental overdose, there is no way in the world . . . you can disagree with me. . . we can talk later, I’ll stay here till midnight, I’m open minded. I personally believe there is no way that a doctor dies by 100% accidental overdose on a drug they prescribe every day to patients. This makes no sense. They totally have been to a million meetings with pharmaceutical reps. They know the narrow therapeutic index.

So it’s either a 100% intentional overdose when a doctor dies by suicide, because they line the pills up and they’ve done the calculations, right, or it’s sort of like a Russian Roulette thing, like partially intentional, “If it happens, it happens, I don’t really like my residency. I’ll see if I wake up tomorrow.” That sort of thing. I think the issue is that we probably are losing a lot more physicians to suicide than we know of, and for each of those doctors that dies by suicide, they each are responsible, at least in family medicine, the average is 2300 patients in your panel.

Now I don’t know how many patients emergency doctors see per year or in other specialties, but if you do the math, let’s just say, 2,000 to 3,000 multiplied by 400+ suicided doctors, you end up with like one million Americans (or more) every year, this just in America, who lose their doctors to suicide. We’ve abandoned one million patients, that is a public health crisis and so now I’m being contacted by patients who don’t know what happened to their doctors and they’re wanting to know,” Is my doctor on your registry?” because they love this doctor, the doctor delivered their first baby. I mean there’s a doctor in Washington State who delivered in a small town 6,000 people in that town, 6,000 babies. He died by suicide in his bathtub, because of like an insurance situation buyout of his clinic. He was the like a third-generation OB/Gyn. Apparently, he couldn’t take losing his clinic to the economic environment.

Just unbelievable. Patients are calling me, trying to get answers to what happened to their doctor because nobody tells them. If we whisper it among ourselves, these one million patients are left to wonder forever what happened to their doctor. You know what they’re told when they call for a follow-up appointment? “Pick another doctor.” Pick another doctor? This guy delivered my baby, saved my life, did my liver transplant. Just pick another one. What are we? Like just commodities? Just ridiculous.

I want to tell you that I actually wrote this article, Why Happy Doctors Die by Suicide. Medscape picked it up. It became one of their top 10 articles in all of 2018. I would highly recommend you read it. I’m going to give you a little quote here, from the article, which I love, this came from a book from 1858, which apparently is where that original quote came from about doctors dying by suicide at higher rates than the general public, but this is really interesting.

Might bring back memories of Robin Williams and others who have died by suicide, looking really great on the outside. It’s a huge problem. This is the book. You have all the slides, so you’re free to grab all the original publications and look them up. This is what’s going on here in medicine. This picture, this tragedy, sort of comedy, sad/happy face like you don’t really know what’s true or not, right?

Here’s another man I’m going to introduce you to. Look at this smile. Look at this beautiful smile on this man. Look at that smile. Is that somebody who’s going to die by suicide?

Well, he died by suicide. He died by suicide and his brother is a doctor. This is Avi at work when he’s not as happy as sliding in the snow with his child, right?

I ended up on Skype with Shai Shimony and another brother. In fact, I didn’t realize this, they had found my “happy” doctor article and read portions of it at Avi’s funeral in Israel. He went on to explain this in an email. Notice how many times he uses the word exactly.

How many other doctors are the exact description of this? So many. If you go on Facebook, you can see beautiful pictures of smiley faces of doctors who’ve just died in the last few weeks. I was going to share this at the appropriate moment here. I just posted this on Twitter a few hours ago:

Okay, so I think the issue is that everyone is just in complete shock and they always in the aftermath want to know, “Wait, he was happy. What could we have done? Could we have done something? How could we have intervened?” But it’s very hard to intervene when all you see is smiley faces.

I interviewed a number of male physicians who survived their suicide attempts and I asked them, “Hey, how long between when you sort of made the decision, ‘That’s it I’m going to die by suicide’ and you actually sort of grabbed the gun, got the pills, started moving?”

Three to five minutes.

Now if we wait till the last three to five minutes, it’s going to take a lot of heroic psychiatrists and such to jump in there and find these people, but meanwhile, these people have had hundreds of missed opportunities, over decades. We’re surrounded by the highest density of health professionals who could help us and yet, we’re sort of not doing anything, that’s working very well or this wouldn’t be a problem, so I am really encouraging you to take action and the action steps are very simple and I’ll talk about that in a minute.

I want to show you a picture of a wall in my home business office that’s covered with the photos of doctors who have died by suicide, and medical students. I really don’t want to add anyone else to this wall. I don’t have enough space. I’m in a 900-square-foot house, I have a very like voluntary simplicity lifestyle. I don’t have enough wall space for this and so we’ve got to really do something about this.

My partner who’s very funny, he’s like, “You know, when you go to these conferences, these doctors’ spirits are still here. I can feel them here. They live in the house, as soon as they die, they move in. This is really not great for our relationship.” I don’t know, I mean, just to salvage my relationship, this guy’s a musician. He says, “I never thought about suicide before I got together with you. Now all we talk about is doctor suicide. Yeah, this is killing our sex life, this is not going to work out. I love you, but we have all these dead doctors, all I think about is dead doctors. This is not inspiring. I don’t feel like making music.” It’s causing slight rift. He’s a sweet guy. He’s like living with the house cat, he’s very sweet but the doctor suicide thing, I mean, I need more people to help.

Okay, full disclosure again, I in 2004 was a suicidal physician myself. I’m not a violent person, so my method. . . I guess I was just deeply depressed, it was 100% occupationally induced. I ended up sort of in bed after quitting my last job, six jobs in 10 years looking for a way to practice real family medicine. You know, the housecalls. It’s impossible to get to know people, like seven minutes in a cubicle, that’s all they wanted me to do. Seven minutes. Just wanted me to generate the most revenue per millisecond. I mean it caused this terrible existential crisis, because I feel like I was born to be a healer. I saw what real doctors did in the 1970s and they weren’t in cubicles and they weren’t doing seven minute office visits so I was just like, “What is this?”

The occupational distress. It caused me to fall into a deep depression and I was praying every night that I could die in my sleep. I was trying to will it to happen. The problem is when you’re 36 and you’re a vegetarian and you’re really healthy, it’s so unlikely to die in your sleep. So I’m still here. I mean, I’m still here and what happened after that, I mean, so I had an epiphany to start an ideal clinic. I was like, “Okay, if I’m not happy and my patients are not happy we’ve got to do something different.”

Suddenly it clicked in me, like maybe I could just ask them to help me start the clinic because I’m exhausted. When you’re depressed, you’re not super-creative about, “how am I going to get out of this.” Right? But I live in a beautiful small Eugene town and my patients love me and I love them and I was just like, I hosted a town hall meeting where I said, “Look, I’m suicidal and depressed. I can’t figure out what to do. I don’t like seven-minute visits. You don’t either. Tell me what you want, I’ll do it, as long it’s basically legal, I’ll just do it.”

They wrote me one hundred pages of written testimony. I just followed what they said and I’ve been happy ever since—for 14 years.

My mom thinks I’m hypomanic. She thinks I use excessive happiness as a coping strategy. I’m totally open now and I’m in a room with all these psychiatrists. If you can DSM me properly, you’ll save a lot of other people the hassle, because I don’t know what’s wrong with me. Am I hypomanic? Am I too happy for no reason? I don’t know, but I believe mental illness appears on a continuum. We all have had experiences with mental health issues. I believe in channeling your mental illness into something productive, like saving suicidal doctors or if you’re manic, go into marketing.

Match up your mental illness with the right profession and give people an outlet. I’m just channeling my (whatever it is) excessive happiness, grandiosity, histrionic I’ve been called, but you know what? I come from a family of physicians and entertainers. I’m related to the Three Stooges. Okay, so it’s like, “Am I being too theatrical?” I don’t know. Hey at family meals when I was younger, I’d sit at the table and my family and it was so funny, I would fall off my chair laughing all the time, because my dad is hilarious. I’m related to all these theatrical people but suddenly when psychiatrists look at me, they’re like, “You’re histrionic.” But I’m an extrovert. I understand most physicians are introverts and  yes, sometimes I wear glitter and they’re like, “Hmmmm . . . grandiosity.” I did a talk in a medical school and I had all these folks lined up with question. I asked this woman, “So what’s your question?” She says, “I’m just here to see if you’re really wearing glitter.” I said, “Yeah, you can wear glitter—and be a doctor. You can be a doctor—and be a human.” It’s possible, I’m proof.

One day I was at my mom’s house. We both went to the same medical school. I’m sitting there. I’m looking through our alum magazine. For some reason, she gets the alumni journal and I don’t usually. I haven’t received any alum stuff from my med school. I’m still paying for therapy to recover from medical school. I don’t have any money to donate. Some suicidal docs have disclosed, “And by the way, what really pisses me off and I just got this thing in the mail, they want me to donate money to my medical school. They gave me all these psychiatric problems. Why do I have to donate money to medical school?”

Anyway, I’m looking through this alum magazine, you know at the end, they have updates on what your classmates are doing and you sort of want to voyeuristically figure out all the awards everyone won that you didn’t and you want to look through there, and it’s like, “Oh, my God.” I look through under obituaries, I saw the name my anatomy partner who I dated. You know how startling that is because he was like 39 and I tried to call his office to see what happened. I tried to track down his family. Then at a certain point I was like, well, let me back up. Leave it to the family, it’s none of my business. I love this guy. I dated him. We did some really interesting things after hours in the anatomy lab, and so it’s like I just wonder what happened to him. Then this other man I dated in medical school for three years, he died suddenly in his sleep. Right, I feel like, “Wait a minute, both men that I dated in medical school are dead, so what is going on here?” 

Let me chronologically catch you up. I open the clinic happily ever after in 2005 on April Fools’ Day and then 2012, I ended up in the second row of a memorial service for the third doctor that we had lost to suicide in my small town in Eugene, Oregon, within a year. Top guys, like top of their game and I was sitting there and as a truthspeaker, you have to know, it was very odd, everyone knew that he had died by suicide, by shooting himself in the head in a public park in the middle of the day. People were all whispering why, nobody said suicide out loud during the whole service. Everyone was  whispering in the bathrooms and the corners.

I was like, “What kind of behavior is this for adults?” Why are we not talking about this? Everyone was asking in whispers, “Why did he shoot himself in the head?” That’s what they wanted to know and it’s like, we’re not going to get very far if nobody will say this out loud, and so I’m sitting there in the second row and I kept hearing this why (I guess I’m an empath). I really pick up on what’s going on in a room, right, so I just kept hearing “Why, why, why, why” and I just felt this, like a reverberation in my head, “Why, why, why, why,” and so I just started counting on my fingers how many doctors I knew personally had who had died by suicide.

Ten. I knew 10 doctors who died by suicide. I was only 41. That’s a lot of people to know in your profession that have died by suicide so I appointed myself an investigator. I wanted to know why my friends were dying by suicide. I had no idea this would lead to me helping my entire profession figure out what to do next. This was a personal quest of mine, because I had lost all these people. Please help me. Please help me. Please help me stop these deaths.

I wasn’t very smart about figuring out why at the beginning. I came up with a list of 35 reasons on the fly that I thought might have been causing doctor suicide in 2012. I published a blog. What was funny is that I had a blog for a year and nobody was coming to my blog. No comments, no likes, no shares. Nothing. As soon I wrote Why Doctors Die by Suicide, it was like 80 comments (now 234) and a million emails and I was like, “Well, this is reinforcing that I probably need to keep doing this.”

Five years later, fast forward, I end up writing a piece, basically what I’ve learned from the first 757 doctor suicides, that was picked up by The Washington Post and then generated, of course, a lot more interest. Media begets media. I was very frustrated at the beginning, because I kept talking about all these older male doctors who had died by suicide and nobody seemed interested.

I couldn’t get the media interested. I told my therapist, “This is so frustrating. Like nobody cares that all these people are dying,” and she tapped me on the shoulder because I’d figured out some solutions and she’s like, “Well, you know, you can’t really solve a problem, that nobody knows exists.” Oh, no. I’ve got to go back to preschool. You know, I’ve got to go back and do a lot of the whole public awareness, decrease professional denial campaign. Frustrating!

Oh, so anyway, what I’m saying is I’m extremely happy that the media has picked this up, that there’s now been a film (view movie trailer here). We’re finally getting the media traction that we’ve needed all along, Now medical conferences like this, forward thinking conferences are really taking this on and so here are some of the things I learned from the first 757 doctor suicides. We’ve known about the high rate since 1858.

Physician suicide is a public health crisis because of just the sheer volume of people who are dying, of a dying family member, loss survivors that are suffering and patients that have been abandoned, like I said earlier and most doctors, many doctors, actually have lost several colleagues to suicide and I sort of had this hunch that, yes, anesthesiologists were number one and number one in a contest you don’t want to win, as the highest risk for specialty because I would get emails from anesthesiologists listing eight colleagues they’d lost to suicide.

I’ve never received any emails from any docs in other specialties with that many losses. You’ll see a graph in a little bit where I actually have numbers by specialty. I thought psychiatrists were highest risk, I mean just from looking at my mom going, “Oh, no, oh, no,” but actually psychiatrists are the highest risk non-surgical specialty.

The methods vary by region, gender, and specialty, of course, you’re using whatever you have, you’re stepping off tall buildings in New York, on the West Coast of the US, using guns. In India, they’re hanging by saris, ceiling fans. They just, you know, three to five minutes, they’re going to pick whatever they have.

Some have been critical because reveal these methods of suicide. “You’re not supposed to talk about this. You’re not supposed to talk about the method. You’re supposed to follow suicide reporting guidelines.” Like how are we going to discuss this as medical professionals if we don’t piece this apart and get the data and the method is so important.

If you Google “doctor found dead in hospital” those are all male anesthesiologists. They all overdosed in closets and ORs and one even happened in our town. A high-ranking official’s husband in my town was dead in the hospital for several days before they found him in a closet of an overdose, an anesthesiologist. This is shocking. Shocking. I mean just shocking that you could be dead in a hospital for that long before somebody noticed.

Top-rated beloved doctors are dying by suicide. Doctors develop occupationally induced PTSD, anxiety, depression, suicidality. The personal problems, some people will blame, like, “Oh, he was in the middle of a divorce.” Well, what caused the divorce? Working a hundred hour weeks as an orthopedic surgeon, hasn’t seen his wife in weeks. Like haven’t had sex in so long, and he’s just throwing money at her to like sedate her because he’s away at the hospital.

Let’s stop blaming personal problems, saying, “He was upset.” Leadership within institutions will defame and blame the deceased: “Oh, she was sad.” Well, why was she sad? Because her human rights are violated, because she’s working a hundred hours weeks, because she’s been bullied. You know, there’s a reason doctors are so desperate and hopeless and my impression here tracks back to professional etiology, including the fact that you’ve not been able to get mental health care without stigma. So many docs feel like they are dying inside because of our profession.  The last straw there was your recent divorce or your disabled child or something terrible, your house burned down, whatever.

If you track back and do a little archaeologic dig, psychological autopsy, you might find that the originating issue is probably professional somewhere along the way. Another huge issue is self-blame. It’s deadly, it hurts doctors. Second Victim Syndrome has been studied by Dr. Stacia Dearmin, if you’re not familiar with her, she’s a physician who has done a lot of work on this, helping other physicians with Second Victim Syndrome.

Medical mistakes have also ed to doctor suicide, even if it’s like it’s not your fault. Even if you did nothing wrong, somehow doctors still have the self-blame thing. “Well, what if, what if I checked the labs? What if I would have changed the medicine?” And then they can’t stand it, they still, they take their own lives. Assembly-line medicine kills doctors like it almost sort of killed me—and censorship is part of the problem. The US media rarely covers doctor suicide, medical institutions cover up suicides, family and religion cover up suicides and the censorship just leads to more suicides.

If we did not talk about high blood pressure, diabetes or schizophrenia, where would we be? Nowhere.

This is a graph I put together of the first 1103 physician suicides with a breakdown of the raw numbers that came to me after the first 1103.

This graph above is not as important as the next one below where I used the 2016 AAMC Physician Specialty Data Report to rank specialties based on the numbers of physicians per specialty. When you break it down based on the numbers per specialty, anesthesia is through the roof.

Anesthesiologists die by suicide at 2.3 times the rate of surgeons and 5.5 times the rate of general internal medicine. According to my data, the first 1103, we need more data. I’m not saying this is written in stone. This is just what I got and it gives us a place to start the additional data gathering. Male anesthesiologists are the highest-risk group. I currently believe the highest risk for suicide are anesthesiologists and veterinarians. Psychiatrists are the highest out of non-surgical specialties for suicide, according to my data.

By the way, doctors end their lives not because they really want to die, they just want to stop the pain and they can’t figure out any other way and they certainly have a lot of access, especially anesthesiologists. What’s surprising that’s sort of not surprising when you think about it is they have a great work ethic until the very end.

They’re smiling and doing complex surgeries and cracking jokes, thumbs up to the surgical team, and then they shoot themselves up in the closet. Like I said late-stage intervention is less effective, you only have three to five minutes, but here are their surprising revelations. Now we’re going to go into solutions and deeper dive. Fact is physicians avoid care for fear of checking the yes box. This is an actual medical licensing initial application for the State of Alaska, a section of it:

Pretty invasive and a violation of the Americans with Disabilities Act. As a result, physicians fear sharing our mental health struggles with the medical board. They’re adversarial. Medical boards exist to protect the public from us, so they’re fishing for reasons why they should keep you away from patients. So physicians fear sharing their mental health struggles with medical boards and with each other because there’s like this subtle sort of suggestion that we should turn each other in.

See a doctor suffering, drinking a few extra drinks at a wedding, turn him in, turn him in. Turn all these guys in, we’ll take care of them. We’ll beat the shit out of them and . . . (Sorry) . . . so this is a problem. This is like, if you’re looking for the archaeologic dig, where do we start with this, this is the number one thing. We’ve got to get rid of these questions. They’re illegal and they are creating a huge hazard. They’re creating this mask scenario where we’re not safe to cry.

A female resident called me one day because she was crying after the death of a patient and she got in trouble, written up at work as unprofessional. She called me because she wanted to know if I had any scientific research proving that it’s okay to cry. You’ve got to be kidding. Is this where we are with our profession?

This summer I did a research project on medical boards mental health questions. I want to give a big shout out to Arianna Palermini, she is a medical student who called me up and wanted to work with me all summer on any sort of project. I said, “Well, grab every single state medical board initial licensing application and pull out the mental health questions, let’s analyze them state by state. Read full research study here.

 

So our overarching question was, “Do medical boards undermine physician mental health by breaching physician confidentiality and privacy?” We analyzed all these applications.

We identified the most favorable states for mental health. Here are three questions to get you thinking about this:

This is a big problem. Violation of our rights to confidential care. So what physicians do is they pretend, deny, and lie. Okay, that’s what we do.

This is the reality of people. I know, many of you in here are lying on their applications. You’re with the majority of docs who have mental health issues. I mean, it’s what people do.

So physicians sneak off-the-grid care.

 

How freaked out do you have to be to sneak care in one direction and then drive a 100 miles in another direction to nervously fill prescriptions for antidepressants?

We also have super-honest physicians. A lot of people are just lying, sneaking meds,  getting prescriptions online, right, but then we have this whole other group—the really honest physicians, like they’re so honest that they want to correctly check the no box, so they will withhold getting care because they want to be honest on their applications because that’s their philosophy of life and their religion and all that, so they have to be honest, right?

How humiliating is that for an introvert who didn’t even have the problem as an anticipatory decision to take the med? I mean, you wouldn’t really believe this unless you’re on the suicide helpline, you hear these stories all the time. They become more believable but when I started all this, all this stuff seemed like the Twilight Zone, like unbelievable. The same woman above reports:

Would you all agree this is a culture of shame created by our own industry? How are we going to be there for school shooters and veterans and everyone else if we are tormented within our own industry? We certainly have to start here first, I would think.

These “approved” doctors and facilities are part of a larger issue with a conflict of interest, kickbacks, lots of things going on with these “approved” programs. Get on my website. Talk to me later. There’s more, much more to this.  [Read about why doctors fear physician health programs here—and view TV investigative reports on what happens to vulnerable doctors.]

Do we really want to create a situation where physicians are scared to get medical care? That’s what we’ve done.

To summarize here, we’ve got three problems. Physicians are self treating and lying, which is a problem, because most of them are not psychiatrists and even if you are a psychiatrist, self-treatment probably not a good way to go. Physicians sneak off-the-grid care and I should have put and lie on that one because the top two are forced to lie and these are people that really probably don’t want to lie, but they feel forced to lie. Then we’ve got the whole big group of honest physicians who won’t get care because they want to tell the truth and they want to check the no box.

Every way you slice and dice this, it’s a problem and so here are the results from this investigation, this research project that we did. This was really fun. What we got to do, I mean it seemed painful at the beginning, especially if I was going to be the one pulling all these reports but thank God a medical student helped me, Arianna, who is a Godsend, but what we did is we actually graded the states from Grade A through as it felt really pleasurable to grade medical boards. You know, after we’ve been graded so much ourselves by just every regulatory body out there. I was like, “Whoo, this is fun. I’m going to grade the medical boards.”

Grade A states had no mental health questions or one to two straightforward current impairment questions that do not mention mental health. 13 states fell in that category. This is a little dense but just go to IdealMedicalCare.org, you can read the full version of this 9,000-word piece with all the hundred comments afterwards and adding your own, if you have an experience. Read full article.

What’s really interesting is Connecticut, Michigan, New York, and Hawaii are the most physician friendly of all states. They ask no mental health or impairment questions. There is the precedent that four states are not asking any questions. In fact, my call to Hawaii Medical Board, it was just so relaxing, because they were like, “Aloha,” which was very different than different from what happened in Alaska, which was 25 yes-or-no mental health questions. Maybe some of this has to do with the climate. I don’t know.

I list Massachusetts here because it’s an example of a straightforward question. The other problem is so many of these mental health questions have multiple commas, clauses, you can’t even figure out (even as a pro at multiple choice questions) you can’t really figure out what the question is aiming at except your career. So this is an example of a question that makes sense. “Do you have a medical or physical condition that currently impairs your ability to practice medicine?” That’s a question anyone can understand and I think that’s good wording.

Grade B are states have progressive mental health questions so they mention mental health but they link it only to current impairment. Grade C states are states with mental health questions where they want to know your mental health for the past five years. Grade D states that have, “Have you ever had questions,” related to mental health, beyond five years or like in Georgia they require peer references where your friends who you work with in the next cubicle get to write about your mental health for you, which is very unnerving and they’re not even psychiatrists, at least most of them, as you know, so it’s a problem.

Here are the worst states: Grade F states and you can see all the states that fit in every category. I didn’t want to burden the slide show with all sorts of detail but I want to do this in the A and F states, just so you could get an idea. These are states with highly invasive mental health questions. Probably each one has 12 commas in there. Unlinked to current impairment. They contain confusing, punitive or adversarial language and we have Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington are the worst.

Alaska has 25 yes-or-no mental health question and is the very worst when it comes to mental health licensing applications and I only looked at the initial licensing applications, to have them analyzed, it took all summer just to do the initial. I didn’t do the renewals. Here are some examples of things people have to say.

I just want to say these are physician health programs these doctors are sent to where you end up in a room with two people with a 10-month community college degree who hold your license hostage and can give you a mental health diagnosis (yet it’s not considered practicing medicine) and then you could lose your license.

This is just total crap. I can’t believe this is going on. The first time I heard about it I thought the person I was talking to was delusional, then I heard it again and again in all these different states and like we have a really big problem with physician health programs. (Note: Some physician health programs have helped doctors with substance abuse issues but not for postpartum depression).

Can you tell I’m a little angry? I am angry about this. I think we should all be furious about this. I think psychiatrists should be at the helm of changing this. I’m happy to help, do my little part as a family doc in Oregon. Please help me.

This guy couldn’t even date because women would look me up online and see all this stuff.

I mean, this is so unfair. The peer reference on mental health is from Georgia which is a Grade D state. They don’t have an impairment or mental health question for the physician, but they want three of your cubicle physician friends to answer, “Does this physician have or has this physician had in the past any, ever, any mental or physical illness or personal problems that interfere with his or her medical practice?”

Do you think Ben Shaffer is going to go tell his colleagues he’s struggling if they might have to fill one of these out. I mean this is a deterrent, a huge deterrent. Now Wyoming is a Grade A state and they require a peer reference but they don’t ask anything about mental health. It’s just a straightforward competency question. That’s fine, I’m not against peer references but stop getting in everyone’s business with their psych history.

The stigma is so severe. I have so many examples. Why not focus on what we really want to know.  Are you safe with patients? These questions pose barriers to seeking mental health care. They create collegial distrust when physicians fear revealing their struggles with peers who may report them to boards so here’s the solutions. Here’s what we do.

We’ve got to remove these mental health questions. This is the number one thing, if we could do this, oh, our profession will be so much better and we won’t lose so many people. Please, I’m begging you. Get rid of these illegal questions, if you’re in one of those states. [Find where your state ranks here.] Over half the states still have these questions that violate the Americans with Disabilities Act. Call all your smart attorney friends. Get them on this and we need to be actively petitioning. You know what, some of these states you can’t even get them on the phone. Aloha was really nice, Hawaii, but like Washington is an F and some people didn’t really think Washington deserved an F. We have been trying to call them. We haven’t got a call back in many weeks.

I mean you can’t even get a hold of these people and then some of the states, were like, “Well, we’ve updated our language,” but you go on their website it still has the discriminatory questions. “You still have the 2012 version up on your website,” and then they have this long my-dog-ate-the-homework story about why it’s not updated. I have a website. I can change things immediately. If there’s a typo. I can go in there right now and change it. I don’t know why it’s taking some states three years to update wording on a question that they decided they were going to update at a committee meeting three years ago. They do this. There are several states that voted to get rid of  illegal mental health questions and the questions are still on there.

Here is the question that I would suggest we use, “Do you currently have a condition that impairs your ability to practice medicine?” It’s very simple, straightforward. Comply with federal law, it’s called the Americans with Disabilities Act, or follow the best practices of Grade A states or maybe the four states that don’t have any of these questions.

Then there is pedophilia and criminal or predatory behavior. Move those to the criminal section, okay. Don’t put postpartum depression and anxiety and seasonal affective disorder next to a DUI and all these other felonies. I mean that’s stigmatizing mental health as a crime. Check out what this one doctor did. I love this guy:


These invasive mental health questions are found beyond medical boards. We have to answer these questions when applying to be in network with insurance companies or hospital credentialing. Once we remove illegal questions at the medical boards, we should across the board get rid of these invasive questions everywhere. So be on the lookout for mental health questions and circle them and make a stink and get them removed. Once people realize this is a problem, physicians are willing to change these questions.

Here are three solutions. Number one, get rid of these illegal questions. Number two encourage everyone to get non-punitive confidential mental health care. I think everyone in a high-risk professions—fire fighters, police officers, all of us in high-risk professions—where we see terrible things, should all be in therapy or have a therapist on speed dial. Should doctors in New York be calling Pamela because they can’t figure out who they could talk to in New York? I mean that’s a population dense state. There’s got to be someone there you trust, right? I mean, I’m happy to do it, but it would be so much easier if there was local help.

So most physicians enter medicine as humanitarians with noble intentions, let’s help physicians be well. How can we as physicians give care to patients that we’ve never received? I’m going to take a breath because that’s important, to breathe and also to allow you to understand what I’m saying.

So the final quote from a surgeon I spoke with the other day:

Finally, my big overall plea that we could all start doing today, I mean I wish I could snap my fingers and get rid of these questions on medical boards. If anyone’s a hacker and knows how to get into these systems, we could get in there and take all those questions off tonight, just talk to me afterwards.

The other one, non-punitive mental health care, please open your office doors, consider seeing your colleagues and keeping this confidential but the most important thing that we can all do today, immediately after this session, into the evening. I’m going to be here till tomorrow. If you want to go out to dinner, let’s all hang out. I’m happy to be your best friend, and we can keep talking about this forever. I’m a late-night person. I stay up till 2:00 or 3:00 in the morning.

If you can DSM me, great, I’d love to know what’s wrong with me, but anyway, what we really need to do is share our stories. It’s therapeutic for you and it’s therapeutic for your colleagues. They’ll be like, “Oh, I’m not the only one.” It creates collegial trust and bonding and it destigmatizes physician mental health, and I would really like to ask that we, at least in this family, at the Psych Congress feel safe enough to take off our mask and be human with one another, we can do that here, I believe with safety.

Here is the summary. Three simple things we can do. Remove mental health questions, number one. Number two, encourage nonpunitive confidential care and share your story.

I have a free audiobook for all of you, which has 53 chapters of physician survival stories. I know it sounds terrifying, the title Physician Suicide Letters. You’ll hear me, my voice lulling you to sleep, maybe it’s better than reading a psych journal and looking at Valium ads as a bedtime story. A few of the people in the book have died by suicide and their parents, of course, gave me their suicide letters and asked me to please publish them.

The rest of them are people who contacted me and I do not use any names in here (outside of the real names of the suicide victims with family permission) so you don’t know who the other still-living physicians are. I altered their identity a bit. They wanted to share their stories with other physicians. The book is like being a fly on the wall on my suicide helpline. “What does Wible do? What is she doing in the woods?” Well, listen to what I say and do and you’ll get a sense of who I am.

I think I’m much more mature now than at the time I published this book back in 2016. I understand this topic a lot better, The book was sort of my initial outrage, like “I can’t believe this is happening and here are some true stories,” book.

I will end with another plea to please help me get all these dead doctors out of my house. I love them, I just don’t have space for this many people in my house. It’s a small house.

My final slide. I’m going to show you, this is a happy doctor. I’m also going to show you, so you understand what a suicidal doctor looks like, so that’s me in 2004. That’s how I looked laying in bed for about six weeks, so that’s a real suicidal doctor. Problem is we don’t see doctors walking around looking like this. You’d have to sneak into their house, take a picture of them.

Some suicidal doctors have sent pictures of themselves to me as they are sobbing on the bathroom floor with just snot hanging out, like just absolutely on the edge of death and they’ve sent me pictures of it. I don’t have permission to share them. So I’m going out on a limb here, sharing my story in hopes that this will inspire all of you to take out your really depressing pictures and show people that you’re human, yet you are still a competent doctor that can run an ICU and help your patients and you actually do cry at night and you have survived being anxious and suicidal—and that actually makes you a better doctor because you actually understand what it’s like to be human and patients want human doctors.”

Psychiatrists reaction to our closing session:

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How to honor doctors who have died by suicide →

Just posted on Facebook & encouraging others to join me in honoring doctors we’ve lost to suicide.

Wow! Just rolled in from a 36-hour road trip to Washington moments ago after facilitating an incredibly healing event to honor the lives of doctors we’ve lost to suicide in Washington. 💔 Honored to have been invited to facilitate the discussion before & after the Do No Harm documentary (view film trailer here) that exposes the hidden physician suicide crisis by two-time Emmy winning filmmaker Robyn Symon. In attendance were several families with loved ones honored in the film: Drs. Bryan Whitemarsh, Shawn C. Kelley, Matthew Seaman with spouses present Shannon Whitemarsh, Vince Nethery, and Dr. Linda Seaman in a powerful panel discussion highlighting how this global crisis impacts doctors & patients in Washington.

Of the more than 1,300 doctor suicides I’ve investigated on my suicide registry (3 more just submitted this week), there are nearly 30 from Washington. I invited all to attend. Eternally grateful for the courageous words of those family members who were able to stand on stage and speak on behalf of their loved ones tragically unable to receive the help they needed despite being surrounded by so many caring physicians in their hospitals & clinics.

Families shared their greatest moments of despair on stage in front of nearly 200 medical students, residents, and medical professionals. Thanks to Yakima Medical Society, Central Washington Family Medicine Program & Pacific Northwest University College of Osteopathic Medicine for hosting the event and sponsoring the film screening that would not have been possible without the incredible planning and organizational power of Hannah Udell OMS2, Dr. Kim Wadsworth PGY2, Program Director Dr. Katina Rue, Dr. Kay Funk (aka Rosie the Riveter). 🙏🙏🏻🙏🏼🙏🏾 Shout out to all the folks who drove in from hundreds of miles away to see the film: Terry Rice NP, Dr. Neil Golan, & so many others plus great to see Dr. Yami Lancaster (who was celebrated in the film for her amazing ideal clinic in Yakima!) 🎉👍

What an awesome display of appetizers before film & dessert buffet 🍰 🍫afterward (with amazing home-baked brownies and treats made by Kim, Hannah & other students). Plus everyone got a free book: Physician Suicide Letters—Answered (that includes chapters about many of the subjects featured in the film).

Our conversation began at 5:30 pm as people trickled into the auditorium and ended at 11:00 pm as the last few of us left the med school and then several of us reconvened in the morning at 9:00 am and continued the conversation while watching the Yakima parade 🎉 from our reserved Hilton breakfast suite right on Main Street!

Wonderful to have Rica Amity PhD and Bridget Beachy PsyD present to help students & residents with mental health needs during & after the film. 💕

So essential to provide a safe and open environment to process emotions after the film screening and to have a solution-oriented local panel discussion to highlight what is being done in Washington to address the crisis. Recent research indicates that Washington State continues to be adversarial with physicians suffering with mental health issues on their initial licensing applications and several present in the room shared how medical board mental health questions had harmed their loved ones stigmatizing and punishing them for occupationally induced psychological distress. Washington is a grade F state in Physician Friendly States for Mental Health: A Review of Medical Boards.

THE GOOD NEWS! This year the Washington State Legislature unanimously passed a Healthcare Whistleblowers Protection Bill. Yakima physicians are also presenting resolutions at the Washington State Medical Association annual meeting on October 12–13, challenging the Washington Medical Commission and the Washington PHP and asking for specific enumeration of physician suicides.

Fact is sometimes physicians are let down by the very systems that they support. Systems have let suicidal physicians down in their times of greatest need and are to blame for their deaths. When we rely on systems to help people we are in grave danger if systems fail. When physicians (who have lost so many colleagues to suicide) are told to be more resilient by a system that is failing them and violating their human rights, we all continue to suffer. Systems don’t save people. People save people. Heartless systems with disenfranchised workers will always fail us.

My greatest hope is that specialty societies will come together to honor the physicians they have lost to suicide, that local communities (hospitals, med schools, med societies) across the USA & the world will come together to honor the doctors they have lost to suicide. I’d love to help honor my brothers & sisters in medicine in any way I can (& have devoted my life since 2012 to this cause). I’ve been running a free suicide helpline for docs & med students for 7 years now. As always, I am here to talk. Reach out. YOU ARE NOT ALONE.

Please join me in breaking our silence & examining the root cause of each suicide so we can prevent the next needless death. If you’d like help organizing an event to honor physicians who have died by suicide, contact me.

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Physician-Friendly States for Mental Health: A Review of Medical Boards →

Physician-Friendly States for Mental Health: A Review of Medical Boards
Research Project by Pamela Wible, M.D., and Arianna Palermini, OMS2
© Copyright 2019

OBJECTIVE
Do medical boards undermine physician mental health by breaching physician confidentiality and privacy? We analyze the initial medical licensing process in each state to determine if qualified applicants who report mental illness experience discrimination. We then identify the most favorable states for physician mental health.

 

INTRODUCTION
Could a pediatrician in marriage counseling 10 years ago be mandated to disclose her therapy records to the state board? Yes. Could a dermatologist with postpartum depression 3 years ago be required to defend her competence before the board? Yes. Should a medical student worry that a licensing board might read his psychological evaluation for test anxiety? Yes.

State medical boards may access applicants’ confidential health records and require that all three individuals defend their competence to practice medicine. Are medical boards injuring physicians by violating their rights? Many say yes.

“Why are mental health questions still allowed to be on there?” asks a physician. “I have had postpartum anxiety/depression three times now and I feel like it is none of their damn business. So I have lied about it on my applications. Also, I feel these questions could contribute to doctors not seeking help, especially for serious problems that could require a mental health hospitalization. Do these questions have an adverse effect on doctors and medical students presenting (or not) for care they may desperately need?”

We all desire competent, healthy doctors who deliver excellent patient care. State medical boards exist to protect the health, safety, and welfare of patients through licensing, investigating, and disciplining physicians. Their mission is to protect the public from impaired physicians, yet medical boards may be impairing physicians’ access to confidential compassionate health care by subjecting doctors to mental health questions that violate United States law.

“After reading an article about one woman’s journey through hell after being honest on those application questions, I sought care an hour away. I drove an hour in another direction to nervously fill prescriptions for antidepressants,” reports a physician. “I required several meds to stop thinking of suicide all day every day. My suicidal thoughts were 100% work-related.”

 

BACKGROUND
Suicide is an occupational hazard of the medical profession. (1) Though students enter medicine with their mental health on par with or better than their peers, they are three times more likely to kill themselves, according to the American Medical Student Association. In some residency programs 75% of interns meet criteria for major depression. (2) Suicide risk increases with untreated mental illness. Physicians who die by suicide are less likely to be receiving mental health care compared with nonphysician suicides. Physicians are more likely to self-medicate for anxiety, depression, and suicidality—with tragic outcomes.

Doctors are reported to have the highest suicide rate of any profession—even higher than the military—according to findings presented at the 2018 American Psychiatric Association annual meeting. (3)

What’s causing our physician mental health crisis?

Physicians are routinely exposed to tragedy and death resulting in occupationally induced anxiety, depression, and PTSD. Yet doctors receive no routine on-the-job support. Instead, they risk punishment when asking for help. State boards, hospitals, and insurance companies interrogate doctors about their mental health, read their confidential medical records, and then deny health plan participation, medical liability coverage, hospital privileges, and state licensure. Doctors with occupational distress may be referred to PHPs (Physician Health Programs) where they are required to participate in 12-step addiction recovery with witnessed random urine drug screens—even when they have never used drugs:

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

While PHPs have been effective for some physicians with substance abuse, physicians have also died by suicide under the care of these programs. (4) PHPs hold a monopoly in the provision of state-board-sanctioned physician assistance services in most states. To avoid punishment by PHPs and boards (that may restrict licensure and publish doctors’ mental health diagnoses online) physicians drive hundreds of miles out of town, use fake names, and pay cash for off-the-grid care.

“I’ve been in practice 20 years and have been on antidepressants and anxiolytics for all of that time,” explains one doctor. “I drive 300 miles to seek care and always pay cash. I am forced to lie on my state relicensing every year. There is no way in hell I would ever disclose this to the medical board—they are not our friends.”

Results from a 7-year investigation of 1,300 physician suicides reveal that doctors (and medical students) die by suicide due to fear of seeking care that would be disclosed on their applications for residency, hospital privileges, and state licensure. Fear of seeking treatment leads to delayed diagnoses thereby increasing anxiety, depression, substance abuse, and suicide. (5)

“Do you know what really hurts? The fact that anyone can look me up on the Internet and read my dirty laundry,” explains one doctor. “I’m publicly shamed [by my medical board], punished for being ill. I will only know peace when I am gone.”

The AMA Code of Medical Ethics upholds the right of confidentiality for all seeking health care. A therapeutic alliance requires trust to allow full disclosure of sensitive and personal information. Individuals receiving care believe their medical records will be safeguarded and only released with their consent. Physicians hold confidentiality sacred and take an oath to preserve it at all costs. Physicians are understandably shocked when their own personal health information is accessed by employers, hospitals, and medical boards under the pretense of “public safety.”

HIPAA (Health Insurance Portability and Accountability Act) provides data privacy and security provisions to safeguard medical information for all US citizens. Information about health status, provision of health care, or payment for health care that is collected by a covered entity (such as a doctor or health center) and can be linked to an individual is PHI (Protected Health Information) under federal law. Though physicians must uphold patient HIPAA rights or face harsh penalties, physicians are expected to waive their own HIPAA rights to medical institutions such as state boards.

The Americans with Disabilities Act of 1990 states: “No covered entity shall discriminate against a qualified individual on the basis of disability in regard to job application procedures, the hiring, advancement, or discharge of employees, employee compensation, job training, and other terms, conditions, and privileges of employment.” Yet competent physicians suffer repeated invasion of privacy and discrimination by medical institutions in violation of the ADA.

 

METHODS
We queried via social media and emailed 6,000 US physicians: “Have you ever faced discrimination, limitation of license, or delay/denial of your medical license due to mental health issues?” A selection of de-identified submissions are published with permission. We analyzed each medical board’s initial licensing application to evaluate mental health questions by state. Most applications were accessed online or by portable document format. When only available through a portal, a login was created. When an application was unavailable or no mental health question was identified, the board was contacted by email and/or phone to confirm the absence or presence of mental health questions and verify wording when present. All mental health and impairment questions were organized on a spreadsheet to compare quantity and quality of questions. Substance use queries were removed to focus on non-drug-related mental health questions. We italicized key mental health phrases for ease of reading and graded states based on invasiveness of mental health questions into five categories A through F.

Grade A: States with no mental health questions or one or two straightforward current impairment question(s) that do not mention mental health.

Grade B: States with progressive mental health question(s) linked to current impairment.

Grade C: States with mental health question(s) spanning the last 5 years.

Grade D: States with “have-you-ever” questions related to mental health, mental health questions beyond 5 years, or a requirement for peer reference on applicant’s mental health.

Grade F: States with highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.

 

RESULTS

GRADE A STATES

Grade A: States with no mental health questions or one or two straightforward current impairment question(s) that do not mention mental health.

13 States: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, Wyoming

Connecticut, Hawaii, Michigan and New York are the most physician-friendly of all states with no mental health or impairment questions.

Indiana asks: “Do you have any condition or impairment (including a history of alcohol or substance abuse) that currently interferes, or if left untreated may interfere, with your ability to practice medicine in a competent and professional manner?”

Kentucky asks: “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgement or that would otherwise adversely affect your ability to practice medicine in a competent, ethical and professional manner?”

New Jersey and Maryland both ask the same impairment questions: “Do you have any reason to believe that you would pose a risk to the safety or well being of your patients? Are you able to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation?”

Maine asks: “Are you physically and mentally able to perform all the essential functions or services necessary to exercise the privileges or services applied for with or without reasonable accommodation? Are you able to perform these functions without significant risk or injury to yourself or others?”

Massachusetts has one straightforward question: “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

Nevada asks: “Do you currently have a medical condition which in any way impairs or limits your ability to practice medicine with reasonable safety and skill? If you currently have a medical condition which in any way impairs or limits your ability to practice medicine, is that impairment or limitation reduced or ameliorated because of the field of practice, the setting, the manner in which you have chosen to practice, or by any other reasonable accommodation?”

Pennsylvania asks only about drug-related impairment: “Do you currently engage in or have you ever engaged in the intemperate or habitual use or abuse of narcotics, hallucinogens, or other drugs or substances that may impair judgement or coordination?”

Wyoming has no direct mental health questions, though reference must answer: “Does the applicant’s health allow for the safe and competent practice of medicine?”

GRADE B STATES

Grade B: States with progressive mental health question(s) linked to current impairment.

12 States: Illinois, Iowa, Minnesota, Missouri, New Mexico, North Carolina, South Carolina, South Dakota, Tennessee, Vermont, Virginia, Wisconsin

Illinois asks: “Do you now have any disease or condition that presently limits your ability to perform the essential functions of your profession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease or condition; (2) alcohol or other substance abuse; (3) physical disease or condition? If yes, attach a detailed statement, including an explanation whether or not you are currently under treatment.”

Iowa asks: “Do you presently have a physical, mental or emotional condition (including alcohol or drug dependence), or do you presently engage in the use of illegal substances that affects or is reasonably likely to affect your ability to perform your professional duties appropriately or which could adversely affect the quality of care rendered by you to patients or jeopardize the safety of patients?”

Missouri asks the same questions as Illinois though adds sexual disorder: “Do you currently have any condition or impairment which in any way affects your ability to practice in a professional, competent and safe manner, including but not limited to: (1) a mental, emotional, nervous or sexual disorder, (2) an alcohol or substance abuse disorder or (3) a physical disease or condition?”

States such as Missouri have updated their questions to avoid stigmatizing physician mental health:

“I have experienced discrimination and delay in getting my Missouri medical license due to my mental illness,” reports a psychiatrist. “I have bipolar disorder in remission for years. Never affected my ability to practice (my only mental illness which has affected my ability to practice has been my PTSD secondary to being a physician, ha!). Years ago the Missouri application asked whether you were diagnosed with a ‘psychotic disorder?’ and it had schizophrenia and bipolar disorder in parenthesis. So of course I had to answer yes. As a result I had to undergo an additional yearly evaluation by my psychiatrist and he had to write a letter to the board saying that I was safe to practice medicine even though I have a ‘psychotic disorder.’ My license was always delayed and it was a nightmare renewing every year. Now the Missouri board has removed that question so they must have caught some heat. But I felt very violated and targeted with that question.”

Minnesota and New Mexico ask the same questions: “Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions?”

North Carolina asks: “Do you currently have any medical, chemical dependency or psychiatric condition that might adversely affect your ability to practice medicine or surgery or to perform the essential functions of your position?”

“I was sued,” reports an emergency physician. “Overwhelmed with grief and fear, I took antidepressants and saw a psychiatrist. I paid cash and considered using a false name. I had already seen the North Carolina Medical Board send a physician to 6 weeks of inpatient alcohol treatment due to a complaint without any proof he was drinking. That saved his license but he owed an astronomical bill.”

South Carolina asks: “Are you currently being treated for any physical, mental or emotional condition that might interfere with your ability to competently and safely perform the essential functions of practice as a physician?”

South Dakota asks: “Do you have a physical or mental condition which would preclude you from performing the essential functions of your practice, job, or in the exercise of practice privileges, with or without reasonable accommodation? Regardless of how this question is answered, the application will be processed in the usual manner. If you have answered this question affirmatively and are found to be professionally qualified for licensure or medical staff privileges requested, you will be given an opportunity to meet with the appropriate entity to determine what accommodations are necessary or feasible to allow you to practice safely.”

Tennessee asks: “Do you currently have any physical or psychological limitations or impairments caused by an existing medical condition which are reduced or ameliorated by ongoing treatment or monitoring, or the field of practice, the setting or the manner in which you have chosen to practice? Tennessee also asks: “Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, voyeurism or other diagnosis of a predatory nature?” (Reference Grade B Section end note on predatory/criminal behaviors).

Vermont has a “Medical condition, treatment, use of chemicals or illegal substances” section that begins with definitions: “The ‘ability to practice medicine’ is a term that includes: 1. The cognitive capacity to make and exercise reasoned medical judgments, and to learn and keep abreast of medical developments; 2. The ability to communicate those judgments and medical information to patients and other health care providers, with or without the use of aids or devices, such as voice amplifiers; and 3. The physical capacity to perform medical tasks and procedures, with or without the use of devices, such as corrective lenses or hearing aids. ‘Medical conditions’ includes physiological, mental or psychological conditions with a non-comprehensive list that includes emotional and mental illnesses, learning disabilities, drug addiction, and alcoholism. ‘Currently’ means recently enough to have a real or perceived impact on one’s functioning as a medical professional. ‘Chemical substances’ means alcohol, drugs (legal and illegal), and prescribed medications.” This section has three main questions, each with a follow-up question and place to upload relevant documents. All focus on current impairment. Two relate to substance use and the other reads: “Do you have a medical condition that in any way impairs your ability to practice medicine in your field of practice with reasonable skill and safety?”

Virginia asks: “Do you currently have any mental health condition or impairment that affects or limits your ability to perform any of the obligations and responsibilities of professional practice in a safe and competent manner? ‘Currently’ means recently enough so that the condition could reasonably have an impact on your ability to function as a practicing physician.”

Wisconsin has five impairment questions: “Do you have a medical condition, which in any way impairs or limits your ability to practice medicine with reasonable skill and safety?” Follow-up questions are: “If yes, are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring programs?” and “If yes, are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the setting, or the manner in which you have chosen to practice?” The fourth question is related chemical substance impairment and final question: “Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, voyeurism?”

Note: Tennessee and Wisconsin have a similar question on criminal/predatory behavior (pedophilia, exhibitionism, voyeurism) as do Alabama, Ohio, Mississippi, and Washington. Medical boards must protect patients from criminal behavior and we do not penalize states for these questions.

GRADE C STATES

Grade C: States with mental health question(s) spanning the last 5 years

9 States: Arizona, Colorado, Idaho, North Dakota, Ohio, Oklahoma, Oregon, Texas, Utah

Arizona lists mental health questions in “Confidential Questions.” The primary question: “Have you received treatment within the last five years for use of alcohol or a controlled substance, prescription-only drug, or dangerous drug or narcotic or a physical, mental, emotional, or nervous disorder or condition that currently affects your ability to exercise the judgment and skills of a medical professional? If so, provide the following: A.) A detailed description of the use, disorder, or condition; and B.) An explanation of whether the use, disorder, or condition is reduced or ameliorated because you receive ongoing treatment and if so, the name and contact information for all current treatment providers and for all monitoring or support programs in which you are currently participating. C.) A copy of any public or confidential agreement or order relating to the use, disorder, or condition, issued by a licensing agency or health care institution within the last five years, if applicable.”

Colorado asks: “Within past 5 years, have you engaged in any conduct or exhibited any behaviors that resulted in an impairment in your ability to practice in a safe, competent, ethical and professional manner?”

Idaho asks three impairment questions. One relates to legal/illegal drug use during last five years. The others are: “Do you currently have or have you had any serious physical or mental condition in past 5 years which in any way may impair or limit your ability to practice medicine with reasonable skill and safety?” and “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgement or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner?”

North Dakota asks: “Within the last two years have you been treated for any physical, mental or emotional condition which impaired or could be said to impair your ability to practice medicine safely and competently?

Ohio asks four mental health questions. The first three are: “In the past five years, have you been diagnosed as having, or been hospitalized for a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety? Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing treatment or received treatment in the past (with or without medication) or participate in a monitoring program? Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the setting, or the manner in which you have chosen to practice? If you receive such ongoing treatment or participate in such monitoring program the board will make an individualized assessment of the nature, severity, and duration of the risk associated with an ongoing medical condition. Have each treating physician submit a letter detailing the dates of treatment, diagnosis, and prognosis.” A final question is: “Have you ever been diagnosed as having, or have been treated for, pedophilia, exhibitionism, or voyeurism?” (Reference end note Grade B section on predatory/criminal behaviors).

Oklahoma asks: “Do you currently have or have you had within the past two years any mental or physical disorder or condition, which, if untreated, could affect your ability to practice competently?”

Oregon has three mental health questions. The first: “Within the past two years, have you participated in a program other than the OHPSP for evaluation, monitoring, or treatment for ANY issue in lieu of or as a condition of resolving a matter before a health care program or facility or a regulatory or licensing board or has such action been pending or proposed? “Issue” includes, but is not limited to, substance use, communication, or boundary issues. (if “yes” provide full details and dates to include the name and location of the diversion program, regulatory Board, healthcare program or facility, and/or court, and reasons for and results of entering the program).”

The second: “Do you currently have, or have you had within the past two years, any physical, mental, or emotional condition which impaired or does impair your ability to practice your health care profession safely and competently? The final question: “Within the past two years, have you been admitted to any hospital or other treatment facility for any physical, mental or emotional condition or substance use disorder which impaired or does impair your ability to practice your health care profession safely and competently? (If yes to either, provide full details and name of healthcare professional providing treatment. Request the healthcare professional send directly to the Board a statement regarding the ability to safely practice medicine.)”

Texas has a “Mental and Physical Health” section with five questions with mandatory submission of another form for any affirmative answer. The first three relate to self-referral to the Texas Physicians Health Program, substance use within past five years, and physical/neurologic condition impairments within five years. The mental health question is: “Within the past five years, have you been diagnosed with or treated for any: psychotic disorder, delusional disorder, mood disorder, major depression, personality disorder, or any other mental health condition which impaired or does impair your behavior, judgment, or ability to function in school or work? If you answered ‘Yes’ are the limitations caused by your mental condition or substance abuse/dependency problem reduced or ameliorated because you receive ongoing treatment (with or without medication) or because you participate in a monitoring program?”

“I am applying for my Texas license and I feel my rights are being violated,” reports one internist. “I have well-managed depression. I was asked do you have a mental condition—yes, and then I was asked does it affect how you function at work—no. I thought that would be the end of it, but now I need a treating physician statement, a statement from my program director, and I need to justify why I said no to it not affecting how I function at work. I’m required to list all my medications from the past 5 years and all physicians who have treated me. How is this not a HIPAA violation? Why are they still allowed to do this? My application has been flagged as ‘impaired’ and needs to go before the board and people who have never met me will decide if I am a danger to my patients. I have no money for a lawyer. If I fight this it can delay my license and my being able to work. My friends with no medical issues were approved months ago and here I am still waiting.”

Utah asks: “If you are licensed in the occupation/profession for which you are applying, would you pose a direct threat to yourself, to your patients or clients, or to the public health, safety, or welfare because of any circumstance or condition? Have you ever been declared by any court or competent jurisdiction incompetent by reason of mental defect or disease and not restored? Utah’s one “have-you-ever” question is far less invasive than those in Grade D section.

GRADE D STATES

Grade D: States with “have-you-ever” questions related to mental health, mental health questions beyond 5 years, or a requirement for peer reference on applicant’s mental health.

9 States: Arkansas, California, Georgia, Kansas, Louisiana, Montana, Nebraska, New Hampshire, West Virginia

Arkansas asks: “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your ability to practice medicine or to perform professional or medical staff duties in a competent, ethical, and professional manner? If yes, explain. “Are you currently, or have you ever been monitored by a Physician Health Committee in any state? If yes, explain, and ask the Physician Health Committee to send documentation of your status.”

California has a “practice impairment or limitations” section with six questions related to substance use, addiction, and mental/physical health. Four are “have-you-ever” questions. Two relate to mental health: “Have you ever been diagnosed with an emotional, mental, or behavioral disorder that may impair your ability to practice medicine safely?” and “Have you ever been enrolled in, required to enter into, or participated in any drug, alcohol, or substance abuse recovery program or impaired practitioner program?”

Non-impaired physicians have been mandated to impaired practitioner programs as retaliation. These programs (PHPs), governed by the Federation of State Physician Health Programs, exist under private contracts in all states except California, Nebraska, and Wisconsin.

“PHPs remain largely non-compliant with ADA laws and regulatory guidelines in assessing medical and psychiatric fitness of physicians,” reports an occupational medicine specialist. They receive revenue from contracts with physician employers and residency programs plus referred medical students/physicians who pay costly out-of-pocket fees or risk career destruction. Physician employers liberally refer to PHPs for virtually any reason. PHPs even encourage third-party referrals. Aggrieved spouses, jilted lovers, market competitors have all successfully required PHP evaluations of physicians.”

Georgia has no impairment or mental health questions though requires three peer references to answer: “Does this physician have, or has this physician had in the past, any mental or physical illnesses or personal problems that interfere with his/her medical practice?” Unlike the single Wyoming (Grade A) peer reference, Georgia requires multiple colleagues to reveal any mental health issue at any time in the life of a physician peer including past personal problems.

Such questions pose barriers to seeking mental health care and create collegial distrust when physicians fear revealing their struggles with peers who may report them to boards.

“Isn’t it more appropriate to ask a reference about a physician’s knowledge, reliability, integrity—performance?” asks an internist. “Mental health questions have a chilling effect that I admit have kept me from seeking mental health support when it would have been wise to do so. Stigma is so severe that I have heard many physicians state that it would be better to die from suicide than be admitted to our hospital’s psychiatric unit.”

“My psychiatrist requested I report to the Georgia Medical Board my inpatient care for a major depressive disorder,” explains one physician. “They stamped a 5-year private consent order on me whereby I had to submit to random urines (though there was no history of substance abuse). If I knew what I would be subjected to over the next 5 years and the expense of hundreds of urines, I would not have fulfilled his request. The toughest challenge was getting through the red tape with hospital privileges when they found out I had been treated for depression. I know dozens of physicians under psychiatric care for depression. They dare not relay such to the Board secondary to what I endured.”

Kansas has four impairment questions. The first: “Within the last 2 years have you been diagnosed or treated for any physical, emotional or mental illness or disease, including drug addiction or alcohol dependency, which limited your ability to practice the healing arts with reasonable skill and safety?” The second on self-medicating: “Within the last 2 years have you used controlled substances, which were obtained illegally or which were not obtained pursuant to a valid prescription order or which were not taken following the directions of a licensed health care provider?” The third: “Have you ever practiced your profession while any physical or mental disability, loss of motor skill or use of drugs or alcohol impaired your ability to practice with reasonable safety?” Given residency widespread sleep-deprivation impairment (and use of stimulants) during residency, nearly all physicians (if responding honestly) would admit yes. The final question: “Do you presently have any physical or mental problems or disabilities which could affect your ability to competently practice your profession?”

“I used samples of Paxil and had my spouse write me prescriptions for Lexapro, Buspar, Paxil, and sleeping pills over the years,” reports one physician. “I did not trust other doctors. I did not want any of this stuff in my records as I did not want to be seen as ‘crazy’ (this is how many doctors refer to psychiatric patients).”

Louisiana asks: “In the last 10 years prior to this application have you had any physical injury or disease or mental illness or impairment, which could reasonably be expected to affect your ability to practice medicine or other health profession?

Montana asks: “Have you ever been diagnosed with a physical condition or mental health disorder involving potential health risk to the public? Have you any physical or mental condition(s) which may have or had adversely affected your ability to practice this profession, included but not limited to a contagious or infectious disease involving risk to the public? If yes, attach a detailed explanation.”


Nebraska asks “Do you currently, or have you had, any physical, mental, or emotional condition which impaired, or does impair your ability to practice your health care profession safely and competently? Within the last 5 years, has any licensing agency or credentialing organization initiated any inquiry into your physical, mental or emotional health?” As noted previously, inquiries can be retaliatory and the question posed by Nebraska would imply physician guilt for having psychological needs.

New Hampshire asks: “Have you ever had any physical, emotional, or mental illness which has impaired or would be likely to impair your ability to practice medicine? A physician with postpartum depression decades ago must answer yes leading to invasion of privacy unlinked to current impairment.

West Virginia asks: “Have you had any interruption in your practice of medicine which might reasonably be expected by an objective person to currently impair your ability to carry out the duties and responsibilities of the medical profession in a manner consistent with standards of conduct for the medical profession?” and “Have you ever had anything occur which might reasonably be expected by an objective person to currently impair your ability to carry out the duties and responsibilities of the medical profession in a manner consistent with standards of conduct for the medical profession?” Though West Virginia mental health questions focus on current impairment and are preferable to the wording of all other states graded D, we have placed West Virginia in this category due to “have-you-ever” questions.

GRADE F STATES

Grade F: States with highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.

7 States: Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, Washington

Alabama asks three mental health questions. The first: “Within the past 5 years, have you ever raised the issue of consumption of drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation, or explanation for your actions in the course of any administrative or judicial proceedings or investigation; any inquiry or other proceeding; or any proposed termination by an educational institution; employer; government agency; professional organization; or licensing authority?” The second: “Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, or voyeurism?” and finally: “Are you currently engaged in the excessive use of alcohol, controlled substances, or the illegal use of drugs, or received any therapy or treatment for alcohol or drug use, sexual boundary issues or mental health issues?

The application explains: “The term ‘currently’ does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather it means recently enough so that the condition referred to may have an ongoing impact on one’s functioning as a physician within the past two years.” We wonder why the application did not instead read within the last two years.

The last question suggests that applicants must reveal if they have ever received any therapy for mental health issues regardless of impairment. For this reason, Alabama is graded F.

Alaska ranks worst of all states with 25 yes-or-no questions related to mental health, many invasive “have-you-ever-had” questions unlinked to current impairment. The first: “Has your ability to practice medicine in a competent and safe manner ever been impaired or limited by any condition, behavior, impairment, or limitation of a physical, mental, or emotional nature?” Alaska also asks: “Since completing your postgraduate training, have you ever been physically or mentally unable to practice medicine for a period of sixty (60) [days] or longer?” The most invasive mental health question we found on any application is: “Have you ever been diagnosed with, treated for, or do you currently have: followed by a list of 14 mental health conditions including depression, seasonal affective disorder, and “any condition requiring chronic medical or behavioral treatment.”

Alaska Medical Board Licensing Application 2019

Alaska Medical Board Licensing Application 2019

“In residency I had to do a rotation in Alaska,” reports a hospitalist. “The application asked if I had ever been on psychotropic medications or in counseling. I had taken Zoloft 12.5 mg for 90 days due to anticipatory anxiety about starting intern year. Fortunately, my fears weren’t realized, so I stopped the medication when the prescription expired. I had also gone to counseling in my fourth year of medical school for a separate relationship issue. So, I answered both questions affirmatively. This resulted in my having to ‘defend’ myself to a panel of people on the Alaska medical board over the phone. They granted my license, but it was a humiliating experience—and definitely created barriers to my seeking care moving forward—both because I have not wanted to be in a position to have to answer those types of questions affirmatively, and due to financial barriers because I will not use insurance to defray costs of counseling since that may be ‘discoverable.’ What a horrible culture of shame those questions create!”

Delaware begins with the same question as Alabama: “Within the past 5 years, have you ever raised the issue of consumption of drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation, or explanation for your actions in the course of any administrative or judicial proceedings or investigation; any inquiry or other proceeding; or any proposed termination by an educational institution; employer; governmental agency; professional organization; or licensing authority?”

Two follow-up questions include: “Are such current conditions or impairments reduced or ameliorated because of ongoing treatment (with or without medication) or participation in a monitoring program or because of the field of practice, the setting, or the manner in which you have chosen to practice medicine?” and “Do you have a mental or physical disability that limits your ability to practice medicine in a fully competent and professional manner with safety to patients? If yes, are you willing to accept a conditional or limited license to practice medicine if it is possible to accommodate such disability?”

Final question: “Do you agree to submit to an examination at your own expense if the Executive Director of the Board of Medical Licensure and Discipline deems it necessary to determine whether your physical and/or mental impairment presents a significant risk to the health or safety of patients or otherwise causes you not to be fully qualified to practice medicine in a competent and professional manner with safety to patients without limitations or accommodations? If no, submit a signed, notarized statement fully explaining your answer.”

Delaware’s application makes an anticipatory request that physicians waive their confidentiality/HIPAA rights and submit to an impairment exam at their own expense before the board reviews the application or meets with the physician.

Florida has six questions. Three relate to substance use and one to physical impairment. Two mental health questions are: “In the last five years, have you been admitted or referred to a hospital, facility or impaired practitioner program for the treatment of a diagnosed mental disorder or impairment?” and “During the past five years, have you been treated for or had a recurrence of a diagnosed mental health disorder that has impaired your ability to practice medicine?” Neither focus on current impairment.

An affirmative answer to any question requires: “A self-explanation providing accurate details that include names of all physicians, therapists, counselors, hospitals, institutions, and/or clinics where you received treatment and dates of treatment. A report directed to the Florida Board of Medicine from each treatment provider about your treatment, medications, and dates of treatment. If applicable, include DSM III R/DSM IV/DSM IV-TR Axis I and II diagnosis(es) code(s), admission and discharge summary(s).”

“When I applied for my Florida license it was delayed by months,” reports a gynecologist. “I was required to have a psych evaluation by an ‘approved’ doctor due my history of depression which was treated and well managed. It fell under the ‘impaired physician’ program and definitely was stigmatizing. To this day I don’t answer those questions honestly anymore and am hesitant to seek treatment as needed.”

“After the unexpected death of a patient, I sought counseling. By a stroke of (bad) luck, I picked the only one in town in charge of impaired physician monitoring. He told the board (though stable) I should be ‘monitored.’ I had to defend myself in front of the Florida board. They laughed in my face and then posted in the local newspapers that I was sentenced to 5 yrs of monitoring. I had mandatory Wednesday group therapy. Though I was an exemplary physician, my employers had to be told why I was unavailable for call every Wednesday. Each time I (re)credential with hospitals, I must explain the whole thing again. HIPAA for me does not exist. I have never missed a single day of work for mental health.

Mississippi application forces physicians to waive all confidentiality and HIPAA rights plus consent to a mental exam at applicant’s expense:

Mississippi Medical Board Licensing Application 2019

Mississippi Medical Board Licensing Application 2019

Similar to Delaware, Mississippi has this additional paragraph: “By submission of an application for licensing to the Board, an applicant shall be deemed to have given his or her consent to submit to physical or mental examinations if, when and in the manner so directed by the Board and to waive all objections as to the admissibility or disclosure of findings, reports or recommendations pertaining thereto on the grounds of privileges provided by law. The expense of such examination shall be borne by the applicant.”

Mississippi also asks: “Have you ever been diagnosed as having, or have you ever been treated for, pedophilia, exhibitionism, or voyeurism, bipolar disorder, sexual disorder, schizophrenia, paranoia or other psychiatric disorder?”
 
Given the forced breach of confidentiality, forced consent to exam, and have-you-ever been diagnosed with mental health conditions such as bipolar disorder unlinked to current impairment, Mississippi is graded F.

Rhode Island has no current impairment questions; however, there are two questions that may preclude a physician who suffered retaliation for a mental health condition during training from receiving a medical license. The first: “During any Professional/Medical Education were you ever dismissed, suspended, restricted, put on probation, or otherwise acted against or did you take a leave of absence for medical reasons?” The second: “During any Post Graduate Training, were you ever dismissed, suspended, restricted, put on probation, or otherwise acted against or did you take a leave of absence for medical reasons?” Having to defend a leave of absence for medical reasons that may have happened decades ago revictimizes physicians who have experienced punishment/retaliation for occupationally induced mental health conditions.

“When I became overwhelmed with abuse I was facing in residency, I begged my program director with tears running down my face for emergency mental health care,” reports an anesthesiologist. “I spent the next few days isolated, confused, exhausted on my couch. I saw a counselor. I started an antidepressant for the first time in my 30 years of existence. By the weekend I felt refreshed with a glimmer of hope. When my program asked to meet with me on Monday, I was sure it was to see if I was okay, to ensure I had no thoughts of self-harm or suicide. I was wrong. The meeting was to let me know I was placed on 6 months probation for being unprofessional. I was flabbergasted, my mouth literally fell open. I couldn’t believe I was sitting in front of the people I trusted with my education and they were able to look at me in my greatest time of need and anguish knowing I was now in counseling and on medication and respond only with punishment.”

Washington has “Personal Data Questions” that cover mental health, substance use, and criminal/predatory behavior with a list of impairing medical conditions that match the Vermont application.

Washington Medical Board Licensing Application

Washington Medical Board Licensing Application

Though Washington asks about medical conditions linked to current impairment and rightfully screens physicians for predatory/criminal behavior, we find the threatening language in the black box to be concerning including the forced breach of an applicant’s confidentiality and privacy.

 

DISCUSSION
The Federation of State Medical Boards (FSMB) defines impairment as a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely. (6) The FSMB focus is the individual impaired physician. But what causes the impairment? Has the impairment been fixed?

“Taking medication for ADHD is analogous to wearing glasses for my nearsightedness,” reports a psychiatrist. “My state licensing question asks, ‘Do you have a condition that could impact your abilities?’ As long as I am wearing my glasses I can see. As long as I am taking my ADHD medicine I can keep fairly focused. What business is it of theirs? Normally I feel guilty for lying about the slightest thing. I was counseled behind closed doors by a faculty who knew of my struggles with ADHD to simply put “no” on the form and leave it at that. This proved to be good advice. I was raised to be extremely honest about everything. When it comes to completing these questions for licensing I believe I am being honest because I was instructed by my respected faculty member to look at the questions in this light: Are you impaired by your condition? No. Then the answer on the application is NO.”

Many states treat illness as impairment. According to the FSMB: “Some regulatory agencies equate “illness” (i.e., addiction or depression) as synonymous with “impairment.” Physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years. This is a critically important distinction. Illness is the existence of a disease. Impairment is a functional classification and implies the inability of the person affected by disease to perform specific activities.” (6)

FSMB believes illness precedes impairment and that physicians may at any point fall into the continuum of inability to practice medicine competently and safely.

Medical board intervention is always directed at the physician, not the system. But what if the system causes physician impairment? Case in point: Resident physicians are legally forced to work 28-hour shifts (or longer due to unenforced caps). (9) Working just 17 hours is equivalent to the cognitive and psychomotor impairment of a 0.05% blood alcohol content (illegal to drive in Utah and most Western European countries). Working beyond 24 hours is equivalent to a 0.10% blood alcohol content (exceeding the 0.08% legal limit to drive in 49 states). Impairment escalates along a continuum and is noted even at 10 hours. (8) Sleep-deprivation-related cognitive and psychomotor impairment leads to medical mistakes and fatal car accidents after long hospital shifts. (9)

Professional boards are tasked with protecting the public. To prevent pilot fatigue resulting in impairment-related plane crashes, the NTSB (National Transportation Safety Board) limits maximum flight time to 9 hours during the day or 8 hours at night. Why force physicians to work three times that amount?

As a guardian of public safety, medical boards (like transportation boards) must address work conditions that currently impair more than 130,000 US resident physicians. (7) Given our physician shortage, boards should protect physicians from sleep-deprivation-related seizures, hallucinations, psychosis and death inside our hospitals. We can’t afford to lose one more doctor.

Beyond sleep deprivation, physicians are injured by chronic violations of their human rights in hazardous workplaces due to overworking (an 80-100 hours work week is equivalent to 2 to 3 full-time jobs), food/water deprivation, bullying, harassment, discrimination, and punishment when sick (including lack of confidential mental health care). (5) Late-stage effects of these violations are substance abuse and mental illness.

Rather than address the systemic cause of physician impairment, medical boards too often revictimize victims.

Some board questions seem more voyeuristic and predatory than helpful, exploiting vulnerable physicians for profit. Fine-print warnings threaten hefty fines for “intentional or inadvertent non-disclosure” leading naively honest physicians to overshare intimate confidential information when they present no danger to patients. One affirmative answer creates a cascade effect in which non-impaired physicians may land in 5-year addiction recovery programs (even though they have never used drugs). When one state denies or limits licensure, others mirror the action. One positive response to a mental health question may follow an applicant for life.

 

CONCLUSION
Medical boards do undermine physician mental health by breaching physician confidentiality and privacy. Discrimination against qualified, competent applicants who report mental health conditions is a violation of the Americans with Disabilities Act. In their search for criminal behavior among physicians, medical boards must not become criminal in their own behavior. By breaking federal law and the AMA Code of Ethics, boards have weaponized mental health diagnoses against physicians. Recommendations for all state boards:

1) Remove mental health questions from medical licensing applications. Replace with current impairment questions such as: “Do you currently have a condition that impairs your ability to practice medicine safely?” Comply with federal law by following best practices of Grade A states. Move criminal/predatory behavior queries to the criminal section alongside felonies and DUIs.

2) Address impairment from hazardous working conditions. Rather than focus on individual victims, engage in high-yield activities that resolve hazardous conditions impairing physicians en masse. To truly protect patients, align with all other industries invested in public safety that have legislated (and enforced) maximum 16-hour shifts, 60-hour work weeks, with minimum 30-minute breaks every 8 hours.

3) Encourage nonpunitive 100% confidential mental health care. Physicians require safe, accessible mental health care to be well-adjusted human beings. Most physicians enter medicine as humanitarians with noble intentions. Help them be well. After all, how can physicians give patients the care they’ve never received?

“Physicians are treated as criminals and tracked more closely than Level III sex offenders,” reports a general surgeon. “Answering all these questions on applications, the subtle, unspoken lesson is ‘you had better be squeaky clean, mentally, morally and physically! If you step off the shining path, bad things will occur.’ I have known 7 male physicians who died by suicide. Most with a ‘happy’ exterior. Why? They cannot confide in colleagues for fear that their colleagues will turn them in to hospitals and boards—and there goes their privileges and livelihood. They cannot confide in their spouses because during rough patches mentally, their marriages are already in trouble. If they share psychological problems, they probably fear that the wife may use this as ammunition in any future divorce. So they keep on smiling—right up to the hour they die.”

Even until their last breath, physicians retain their work ethic. Some doctors are completing chart notes, returning lab results, and checking in on hospitalized patients in the hours before their suicides.(5)

By injuring physicians, we aren’t protecting the public.

Let’s end the physician mental health witch hunt.

 

© Copyright 2019 Pamela Wible, M.D.
For authorization to reprint, contact author.

___________________________________________

REFERENCES
(1) Vogel, L. CMAJ. 2018 Jun 18; 190(24): E752-E753 Has suicide become an occupational hazard of practicing medicine?
(2) Pereira-Lima, K. Academic Medicine: 2019 Jun; 94(6): 869-875 Residency Program Factors Associated With Depressive  Symptoms in Internal Medicine Interns: A Prospective Cohort Study
(3) 2018 American Psychiatric Association annual meeting. Doctors’ Suicide Rate Highest of Any Profession
(4) Wible, P. Medscape. 2015 Aug 28. Do Physician Health Programs Increase Physician Suicides?
(5) Wible, P. 2019. Human Rights Violations in Medicine: A-to-Z Action Guide
(6) Federation of State Medical Boards, Policy on Physician Impairment. 2011
(7) AAMC Workforce Data Report. ACGME Residents and Fellows by Sex and Specialty, 2017
(8) Dawson D, Reid K. Nature. 1997;388(6639): 235. Fatigue, Alcohol and Performance Impairment
(9) Wible, P. 2017 Mar 10. Sleep-deprived doctors disclose hospital horrors

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A call for submissions on physician mental health →

As co-editors of a special issue of Qualitative Research in Medicine and Healthcare, we invite you to submit your manuscript on physician mental health. Suicide is an occupational hazard of the medical profession. Though students enter medicine with their mental health on par with or better than their peers, they are three times more likely to kill themselves, according to the American Medical Student Association. In some residency programs 75% of interns meet criteria for major depression. Suicide risk increases with untreated mental illness. Physicians who die by suicide are less likely to be receiving mental health care compared with nonphysician suicides. Physicians are more likely to self-medicate for anxiety, depression, and suicidality—with tragic outcomes. Have you had a personal experience with losing a colleague in medicine to suicide? Have you struggled with mental health as a medical student or physician? Submissions can be theoretical, empirical, or present state-of-the-art reviews of important subject matter on physician mental health/suicide, but they have to advance scholarly knowledge and contribute to research practice in an original way.
 
We welcome submissions before October 31, 2019.
We can’t wait to read your story!
 
Mariaelena Bartesaghi, Ph.D., & Pamela Wible, M.D.
 
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NBC News: The Real Reason Doctors Burn Out →

View on NBC News. Full transcript below.

Medical Resident: Frustrating is way too benign of a word. It’s an infuriating system that we practice in.

Dr. Umut Sarpel: I don’t think most doctors get burnt out by doctoring, it’s everything else that comes along with it.

Dr. Pamela Wible: So we’re on the edge of life and death every day trying to save our patients’ lives, and for people to now start to understand that we have the highest suicide rate of any profession or that we are struggling en masse, this is not a popular thing to discuss. However, not to talk about it just perpetuates the problem.

Dr. Red Schiller: In many ways, we will look in this era as a dark age of medicine. As amazing as the advances are in technology, we’re failing in our ability to recognize our humanity.

Narrator: In today’s increasingly stressful, complicated world, we’re mentally, physically, and spiritually ill. And we turn to our doctors to heal us. But what most of us don’t realize is that many of them are more stressed and more burnt out than the rest of us. And it’s not because of the reasons you’d expect.

Dr. Umut Sarpel: A lot of medical students will ask, when they’re considering what field to go into, “How do you do surgical oncology? It would be so stressful.” That kind of stress, you sort of signed up for. I really love working with my hands. When I’ve done an operation, there’s something very concrete that you’ve accomplished, you know, technically challenging, but also really rewarding. Sometimes you just feel like the weight of the world is on your shoulders, especially when someone is optimistic you’ll remove the tumor. But, again, that’s the job that I signed up for, and people would be surprised that that’s not what wears you down at the end of the day. It’s everything else that comes along with it.

Narrator: There’s a silent pandemic that’s been spreading throughout the medical world. Doctoring is no longer just about doctoring. The amazing promises of technology have made for an exhaustive amount of bureaucratic tasks, like filling out electronic health records, or EHRs, which take doctors away from what they were trained to do, and put them, well, here. Today, for every hour a doctor spends with a patient, she spends at least double that charting it. So these EHRs, which lengthen already really long work hours, coupled with a lack of control and trying to diagnose and heal within a convoluted healthcare system, all contribute to doctors now having the highest burnout rate of any profession.

Dr. Red Schiller: In many ways, the healthcare system needs its own doctor. There’s this focus on quantitative performance that’s really altered the way in which doctors practice. And that’s not something that’s easy to do when people are receiving care with open-ended questions and complex concerns. People talk about a six-minute visit, a 15-minute visit, really sort of a helplessness that a lot of doctors feel that, “I spend all this time being educated, yet we’re really treated like, ‘Here’s the amount of time that you have, here’s the amount of people that you need to see, and here’s your quantitative goals that you need to meet at the end of the day, at the end of the quarter.'”

Dr. Red Schiller: Okay, thank you. Sounds fine.

Patient Bernice: I’m alive?

Dr. Red Schiller: More than alive. Vibrant.

Dr. Red Schiller: Medicine has lost its identity as a profession. So patients are really victims of the stress generated with people that they see.

Patient Bernice: I don’t know.

Dr. Red Schiller: So what would you like to talk about today?

Narrator: Bernice knew why I was filming, and so she went for it.

Patient Bernice: I really would like to talk about the medical profession.

Dr. Red Schiller: Oh boy.

Patient Bernice: No, not you. They don’t know who they’re talking to, and I’m constantly having to say, “Please look at me.” You look. You know who I am.

Dr. Umut Sarpel: I hear all the time people saying that they feel like their doctor never listens to them. And in the back of my mind, I want to say, “It’s because there’s all these other things going on that are wholly separate from taking care of the patient.” People would be surprised to know that when I’m seeing a patient and we’re doing surveillance to make sure that their cancer has not come back, oftentimes the insurance companies will deny a part of their scan. My office will have to discuss with the insurance company, I was going to say argue, but it’s not an argument, justifying that that scan is important. That takes time. That adds aggravation.

At some hospitals, the reimbursement scheme creates perverse incentives for physicians where you are rewarded by your productivity. And while productivity is a good thing, it doesn’t always equate with what’s best for the patient. We’ve been forced to shorten the amount of time that we allot for appointments, and we have a computer in the room, and there are some people who find the only way that they can make their day work is if they’re documenting at the same time that they’re talking to the patient.

Dr. Red Schiller: Yeah. Can you imagine other service industries where, a front desk at a hotel, where the person turned their back on you while you were trying to register? And these probably don’t always have simple solutions. But they’re crucial.

Dr. Umut Sarpel: I mean, there are doctors that would just rather completely leave the healthcare system than work within it.

Medical Resident: This system is exploiting everyone inside of it. So you have pharmaceutical companies bent on making as much profit as they can off of meds, health insurance industries bent on making profit off of people and denying people’s claims to get healthcare, we have hospital systems, sometimes for-profit systems or sometimes systems that operate like for-profits even though they don’t have those titles. So we have physicians who are going into that medical industrial complex that are supposed to operate inside of that, and I think that a lot of people don’t really realize the amount of anxiety, depression, and suicide among physicians.

Residency Survival Guide

Dr. Pamela Wible: I’m a family physician in Eugene, Oregon, and I run a suicide hotline for physicians who are suicidal. When I was 36 years old and I became suicidal as a physician, I thought I was the only suicidal physician in the whole world. This is a common experience because this is not discussed. In the general public, 12.3 out of every 100,000 will die by suicide. Among veterans and military, it’s 30. And among doctors, it’s 40 per 100,000. We lose approximately 300 to 400 doctors per year in the US—the equivalent of losing an entire medical school of medical students to suicide.

Medical Resident: The more that you are told, “You’re such a great person, and doing such a great job,” it’s much harder for you to admit that, “Maybe I am suffering just like the person in front of me that I’m supposed to be caring for and working with.”

Dr. Red Schiller: We don’t really encourage a strong sense of community among the people who are learning medicine, teaching medicine, and providing medicine. We have more robust health services, but there is still, in our profession, and really in our society at large, this sense that if you can’t cut it, you’re weak.

Narrator: Burnout has become so pervasive that medical institutions across the country have installed chief wellness officers to deal with it. And this is Mount Sinai’s.

Dr. Jonathan Ripp: One of the reasons why this is gaining more attention is that it’s not just affecting members of a healthcare professional team, but the patients that are cared for by them. And so, if you . . .

Narrator: Everyone.

Dr. Jonathan Ripp: Right. There’s a large literature that shows that burnout correlates with medical errors.

Narrator: Medical error is the third leading cause of death in the United States.

Dr. Jonathan Ripp: Productivity of physicians, I think they’re already talking about a physician shortage. So in some regards, you can think of it as a public health issue.

Narrator: Or maybe it’s a public health issue in all regards.

Dr. Red Schiller: As part of the Mount Sinai community, I want to recognize their commitment to making this difference. I think the challenge is that this is a problem that’s not going to get solved by tweaking the edges. There’s wellness programs, health insurance plans have wellness programs, and what they all tend to focus on is self-care.

Dr. Red Schiller: The onus is on individuals to get well. The reality is a lot of the things that are making people unwell are things beyond people’s control. So you can’t breathe yourself or meditate through the challenges of having an EHR.

Medical Resident: You can cover me in as many essential oils as you want and give me as many granola bars as you want, but unless you actually restructure how the system functions, then don’t talk about caring about me or my peers or anybody else.

Dr. Jonathan Ripp: I think everyone recognizes that we’re likely to have the greatest impact looking at those system-level drivers. We really need to be smart about how we think about the efforts that are going to improve well-being, and look for those that are likely to have win-wins both on the bottom line and in well-being.

Dr. Umut Sarpel: Maternity leave I think is a perfect example of how wellness is sometimes at odds with the hospital’s bottom line. It’s pretty clear that the right thing to do is to not apply a financial penalty to women for having children, and yet at the end of the day, from the hospital’s perspective, there’s a side that has a hard time seeing that they should be paid for that time.

Dr. Jonathan Ripp: Obviously the healthcare system has a pressure to meet its bottom line and a budget.

Dr. Pamela Wible: We have not been dealing with this like you would expect a profession that’s based on human health and relieving suffering and death. We have not addressed our own internal problems.

Narrator: Nurses across the country have been protesting unsafe staffing levels. Residents and fellows are joining unions. Everyone is feeling the strain. Yet things have truly yet to change. And at the heart of all of this remains that core question of how to deliver good care and how to heal.

Dr. Red Schiller: Think about Paris.

Patient Bernice: I’m planning a trip with my niece.

Dr. Red Schiller: You can’t talk though. Now you can. Thank you.

Patient Bernice: Is it bad or good?

Dr. Red Schiller: Good. Better than mine.

Patient Bernice: Yeah.

Dr. Red Schiller: It’s 122 over 82.

Patient Bernice: That’s good.

Dr. Umut Sarpel: What is at risk the most is the relationship with the patient, which is heartbreaking because, at the end of the day, we went into this field because we really want to help people.

Dr. Red Schiller: What we forget is that being a doctor is really a calling, and it’s a gift. In some ways, the place to start is to just recognize that both the patient and the people providing care bring all this stress to the interaction, and possibly just taking a moment to acknowledge that. I suppose that to me is how I try to deal with this on a day-to-day basis is just focusing on being present. The early days of my training were in the midst of an AIDS epidemic, and I saw things that were just horrible about people with AIDS being turned away. But it was certain people who are able to rise to the occasion and show others how not to be afraid, and I think each generation really needs to do that. You can’t do it alone.

Dr. Umut Sarpel: I think 10 years ago, there was no discussion of wellness. Maybe we were expected to be the bastions of wellness, and that’s obviously not true. So I think this added attention is important, and hopefully something will come of it. I hope there’s hope.

Narrator: Our society still thinks of doctors as these all-knowing, always correct people on a pedestal. But the truth is they are people too, and stress tremendously affects them. And this is why being conscious of what’s happening outside of the exam room is so important for our own health. And it’s also why the big changes that have to be made to this system are vital for the well-being of clinicians everywhere—and for us all.

Not burnout, not moral injury—human rights violations

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