Frank H Netter MD School of Medicine Commencement 2019 ~ Dr. Wible →

Graduates selected Dr. Wible to deliver final inspiring words before becoming physicians. View speech, download MP3, or read full transcript below: (the audio podcast is BEST because you can hear all the laughter & audience reaction) . . .

In less than 30 minutes you will all finally be physicians! (cheering) And this summer you’ll be set loose on your very own patients. (laughter) How exciting is that? Maybe a little nerve-racking.

During your career (depending on specialty and work ethic) you may care for more than 100,000 patients—only a few will live in your heart forever. You will join them on a sacred journey for two. Trust them. They will guide you from nervous new doctor and teach you how to be a healer.

As a new intern, I was assigned to Emily. She had idiopathic bronchiectasis (a fatal lung disease) and refused to take her meds so the transplant team signed off on her case. They abandoned us. We were both 25. Sobbing uncontrollably with her oximiter alarm shrilling, she looked to me for help. I didn’t know how to help her die. So I snuck my dog, “Happy,” into her room for midnight excursions. With her portable oxygen tank rolling behind us, we’d hold hands and disappear across the hospital parking lot into a blanket of grass and gaze at the stars where she’d share her grief of never giving birth or finding her soul mate. Emily and I became soul sisters on an adventure of a lifetime. . . until the day, in her bedroom sitting beside her body wrapped in a Mickey Mouse blanket, I signed her over to the morgue.

Emily has never left my side.

Patients like Emily will hold your hand and lead you to places where there is no algorithm, no attending, where you have no earthly idea what you’re doing. All you’ve got is each other.

After Emily, Harold stumbled awkwardly into my heart. A loner who distrusted technology (and doctors), he lived in the woods caretaking a wildlife sanctuary with no electricity. No phone or car. But he had great health insurance (through his employer). His ex-girlfriend recommended me. So he’d hitchhike to my office—3 hours each way. One day he came in, his back covered in nodules. I excised one, sewed him up, gave him a kiss on the forehead, a slip for a chest X-ray, and an appointment to return next week. It was metastatic lung cancer. He chose chemo, moved to the city, got a cell phone, and quickly spiraled to his death. I got him back to his cabin. He died the next day. His ashes now food for the forest he so loved—where I visit him each fall.

I think Emily kind of helped me with Harold. You’re never really alone. Some patients follow you forever.

It’s weird that I only remember one patient from med school—Veronica—end-stage kidney disease. I still see her alone in her crib in that dark hospital room where I’d lift her up and sing her to sleep in a rocking chair. My peds attending walked by (and this landed in my permanent record) and he said, “Dr. Wible, you are a doctor when your patients need a doctor and a mother when they need a mother.”

I’m proof you don’t need to maintain professional distance. I prescribe professional closeness. You can be a doctor—and be the real you. Is it legal to kiss dying patients? I don’t care. I do what’s right for patients. You will stray from evidence-based guidelines to do the same—because what patients truly need has no ICD or CPT codes and never requires a prior authorization. As an intern do something so epic it can’t fit into an EMR.

Our biggest threat to patient relationships is what I call “assembly-line medicine.” I’m a womb-to-tomb, till-death-do-us-part physician. My dream of being a small-town family doc doing house calls was way too big for my little cubicle. If your dream is bigger than your cubicle, leave your cubicle. You can practice medicine your way—as an employee, a business owner, or an entrepreneur.

If you’re freaking out over your debt or end up hating residency, don’t despair. You can launch your own practice with one or two years of post-graduate training—and if you register it as a nonprofit, you can totally get your loans forgiven! (laughter) Doctors I know are doing this now!

As a physician employee in a big-box clinic, I was so miserable—even suicidal. Then I did something really crazy—I asked my patients for help. I invited them to design their own ideal clinic. I invited them to write my job description for me. And I promised to do whatever they wanted (as long as it was basically legal). They shared 100 pages of their most creative ideas. We adopted 90% of their feedback and opened our community clinic one month later without any outside funding—where I’ve never turned any patient away for the last 14 years for lack of money (clapping) and this is the first ideal clinic designed entirely by patients.

My patients saved my career—and my life (’cause I was thinking of working at Starbucks and doing something totally different—but I probably wouldn’t have gotten the job because I was overqualified). Luckily my patients came to my rescue and I want to assure you that your relationships with patients will  save you from lawsuits. (Patients don’t sue doctors they love.) I’ve been running a physician suicide hotline since surviving my own close call. Several docs told me their suicides were actually averted by a patient thank you card! Keep your thank you cards. Read them often. On your worst night, those letters may save your life.

After speaking to thousands of suicidal physicians who survived, I noticed one trait they share (very unusual among doctors)—they asked for help. The most common phrase I hear: “I would have been one of your statistics, but you called me back right away.” They’re shocked that I called them back. I ask, “When you’re on call, do you respond right away? Why not do that for each other?”

In your last few minutes as a medical student, take a good look at the person to your right and left. Hold hands for a minute please (aw so cute! – laughter) I’m asking you to please be on call for each other.

Look, listen, and feel—notice when a doctor is struggling. Look up at all your beautiful, proud parents celebrating you today. Promise to watch over each other so no parent ever gets a call from the police telling them their child has died in residency.

I was tasked with delivering a few uplifting words today—and they’re coming! (laughter) For now though you might want to keep holding hands. This is tough to hear, but so important for your future.

A med student in the Army Reserve told me she was less stressed in Afghanistan during active sniper fire (than med school!). Here’s why: She had total trust in her comrades. She knew if killed by enemy fire, she would be brought home, covered in an American flag, and honored with a proper burial. They had her back. In med school, she never knew who would stab her in the back. Trying to change that culture here starting with your generation.

We are brothers and sisters in medicine. Protect and defend each other. If a resident is being pimped with esoteric questions, say, “I don’t think any of us know the answer. Let’s look it up together.” Please do that.

When in doubt, hold hands.

Be like the preschoolers on the wooded path by my house each morning. There’s so cute. Almost makes me want to have kids, but not really (laughter). It’s much easier to have you as my kids, already diaper-trained and everything, you’re already know how to bathe, tie your shoes. I’ve just never really been into the young kid thing. Looks really difficult. Anyway, I don’t know if you’ve heard of this, getting rope trained. There’s a rope they hold on to and they each put one hand on the rope so they learn how to walk in a line equally spaced and they are the cutest thing in Oregon with all their tiny colorful rain coats and little tiny rain boots. When one kid slows down to look at a mushroom, they all stop to look.

That’s what we should be doing. Stick together. Hold hands.

I’ve taken hundreds of doctors on hot springs retreats, soaking together in the bubbling Lithium-infused water under the stars in the ancient Oregon forest where Harold once lived (where his ashes are). We go out on a cliff overlooking the Breitenbush River—so amazing! Wild how Harold’s kind of helping me heal doctors now. Weirdly, more than once a doctor at the retreat has told me, “I don’t know why I’m here. I don’t even like doctors.” I think that was Harold’s opening line during our first office visit. Took me years to deconstruct that comment from a physician.

Why do doctors dislike doctors? Hurt people hurt people. Wounded healers wound each other. Most people don’t bond over codes, crash carts, and stillborns. Bonding over trauma creates trauma bonds (leading to maladaptive drug and alcohol use to numb the pain). Befriend each other by doing stuff normal people do. Go on a hike and cook dinner together. As interns, the best way to prevent trauma bonds is to first bond over your hopes and dreams.

Now to celebrate . . .

My #1 recommendation—always keep your umbilical cord plugged into your dream.

Reflect back on medical school. Remember how you felt on your favorite rotation or with that attending who inspired you to go for your dreams. Maybe you have a patient like Emily or Harold or Veronica who touched your heart. Go back to those precious moments, and ask yourself these 3 questions: 1) Do you ever feel so excited you can’t wait to get to work Monday morning? 2) Are you having so much fun at work you would do it for free? 3) Do you love your job so much you never want to retire?

Raise your hand if you answered yes to any of these questions. Oh good! Your dreams are still alive. (Turning to the professors) “You kept their dreams alive! What a great crew of teachers.” 

To those of you who raised your hands. Seemed to be the majority. I want you to realize you are very fortunate to still have passion for your career (which you should have when you graduate medical school).

During a keynote in Vegas, I asked those same questions to 4,000 doctors. Everyone was laughing (to hide the pain of losing their dreams). I can still answer yes to all 3 questions—and so could about 20 doctors (out of 4,000). May you be one of those 20 doctors to create such an amazing life in medicine, you’ll never need a vacation.

Inspired by a Zen poet, I’ll conclude with this: Physicians who are masters in the art of medicine make little distinction between their work and their play, their labor and their leisure, their mind and their body, their education and their recreation, their love and their religion. They hardly know which is which and simply pursue whatever they do with excellence and grace, leaving others to decide whether they are working or playing. To them they are always doing both.

May you be blessed on your journey.


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Susan lost her doctor to suicide. She wants to know why. →

Susan Kreischer is one in a million.

One of a million Americans to lose their doctor to suicide—each year.

She is still devastated years later.

“I had awful back pain—was barely walking when I met Dr. Ortiz and right away we bonded. Every time I went in, he’d give me a huge bear hug, lifting me off the floor (and I’m a heavy woman). He always had a big smile on his face. He was it. He was the man. He didn’t just hand me another pill. He actually got in there and solved my problems.”

Dr. Ortiz was a man who never gave up on his patients.

“Later when I had more back problems, he said I’d need my hip fused and he’d look for another surgeon since that wasn’t a procedure he was familiar with. Next time I saw him he told me that he didn’t find anyone he could trust so he was going to do it himself—and that’s exactly what he did. He learned that procedure for me! I was in awe that he did that for me.”

Staff in the operating room were in awe as well. Nobody could believe how perfectly Dr. Ortiz performed her fusion.

“I saw that man five times in a day and a half in the hospital, plus he went to see me another four or five times when I was in recovery. He called me every night at home to make sure I was okay—and I was.”

Susan wonders how she’ll ever replace him.

“I don’t trust other orthopedic doctors around here. I had some very bad experiences. I had so much faith in Dr. Ortiz because I knew he was being truthful—giving me his honest opinion. I adored him. He was a saint to me. He took so much of my pain away. He changed my life.”

Now all Susan has left of her doctor is this picture she snapped of a framed photo that hangs in the hallway of the hospital where he once worked.

Dr. Ortiz was clearly one of the most thoughtful, compassionate, and ethical men one could ever hope to meet—especially when needing back surgery.

Once when Ortiz was on a vacation, his patient became sick and Ortiz flew home early to take care of her. What kind of surgeon does that?

A patient case was cancelled one day because the hospital did not secure an assistant for the surgery. However the patient had already been sedated with Versed to calm her anxiety so she couldn’t drive home. Ortiz held her hand and explained the situation to her. He then decided to drive her home in her car more than an hour away. He took a cab all the way back to the hospital.

Who was Steven Ortiz?

As a child, Steve was a hard worker who put all his efforts into school. His teachers were impressed by his intelligence. He never got into trouble, always did his homework and turned in all his assignments without prodding from his parents.

Steve had beautiful blue eyes and at a very young age he starting receiving unsolicited attention from older women. One day, after a doctor’s appointment, he was thirsty so he asked his mom to buy a drink. She parked in front of a store and gave him a dollar. He came back out with his drink and handed his mom the dollar. Steve told her that the lady in the store said, “I have beautiful blue eyes and I don’t need to pay.”

“We marched back into that store and told the woman he had to pay for his drink and he did,” says his mom. “Oh the trouble he could have gotten into with those eyes.”

Though we never met, I feel I know Steve Ortiz. Maybe it’s because he grew up down the street from me in Eugene, Oregon. He attended Sheldon High School where he played on the football team and never lost a game. He kept up his grades and was an all-around good kid.

After high school, Steve was a sprinkler fitter for 10 years, then became a fire sprinkler engineer for his father’s company. He also worked in construction. One day at work he stepped off a curb and tore his meniscus. He had surgery immediately and on follow-up when the doctor showed him his x-ray he almost passed out and had to be helped to sit down by the nurse. He literally couldn’t stand looking at his own x-ray.

He returned to school at 28 earning a chemistry degree from Fullerton Community College then a full scholarship to UC Irvine and Stanford Medical School before completing orthopedic residency in New York and spine surgery fellowship in Minneapolis—19 years of medical education!

Despite the demands of nearly two decades of medical training, Steve never forgot birthdays, holidays, or special occasions. He moved his family to Stanford for medical school just before his daughter turned 13. She hadn’t made many friends so she didn’t know how to celebrate her birthday. On her birthday her dad came home and told her he rented the entire medical school auditorium for the afternoon and he invited her whole soccer team to watch a movie and help her celebrate. He even rented a popcorn machine and bought everyone candy.

Steve Ortiz and his children

“He was very observant, always watching, always listening, and always learning,” says his daughter Alyssa. “Once I saw a string of pearls in a picture and I commented that they were very beautiful. I never said I wanted them. A few months later a package came in the mail with the same type of pearls. These surprises happened many times in my life. He was a wonderful man.”

Yet Steve—such a devoted family man—had to sacrifice relationships with the very people he loved the most so he could help heal others. With his kids and wife finally settled in California, he was distraught having matched in New York for orthopedics. During his five years of residency he only got to see his kids once per year. That marriage eventually failed and he remarried a woman who wanted to be near her family in Florida. So, of course, Steve agreed. (With loved ones he had trouble saying no!) So after fellowship, he set up his practice in a Florida hospital where he was adored by patients and staff.

“I want you to know the nurses were drooling over this man. The nurses always said, ‘He is so hot!’ and once I even tried to hook him up with my daughter,” claims Susan Kreischer. “I told Dr. Ortiz, ‘If you ever need any jewelry for someone special, let me know. I make jewelry.’” For Susan, he was more than a doctor; he was her friend.

In the aftermath of his suicide, I’ve received a constant stream of emails from his patients, colleagues, even his college girlfriend. They all want me to know what a truly special man he was.

Kind and generous, Steve helped anyone who needed it. He showed up at a colleague’s house unannounced when she was moving. He brought boxes, tape, wrapping paper, and marking pens and spent his weekend helping her move.

When not attending to patients, Steve adventured in the outdoors. He was a certified scuba diver, a hunter, a motorcycle enthusiast, a fisherman, he even hurt his knee again skateboarding around Florida. Yet his top priority was always caring for his patients.

Typical of doctors, Steve spent his time helping others and rarely asked for help.

Working 80-100 hours each week, surgeons often experience marital distress, and divorce is not uncommon. Back when I was in medical school, surgical residency programs bragged about having 100% divorce rates—as if total devotion to the surgical profession and absence of any personal life would make the best doctor.

Steve did confide in Sherry Cleveland, his surgical nurse. “He called me the annoying little sister he never had because we would goof off and pick on each other during OR days,” says Sherry. “He was in the midst of his second divorce and the Friday before his death he came out with a bunch of us and stayed longer than usual. We were talking about doing the VIP area at the brewery. He was very popular with the ladies and we joked about hosting a ‘Date Dr. Ortiz’ event there. He laughed. When he left he hugged tighter and longer than he ever had before.”

The most unforgettable story about Steve—the ultimate fix-it-guy—is the way he dealt with the giant pothole in the hospital parking lot. No spine surgeon wants patients bouncing up and down in potholes. Since the hospital didn’t have a plan to repair it, Dr. Ortiz went to the hardware store, bought several bags of cement and gravel and he fixed it himself early one morning—before a full day of surgery.

Imagine a sweaty spine surgeon repairing potholes on the hot Florida asphalt before scrubbing in for his next case.

Yet Steve’s problems with the hospital were deeper than parking lot potholes. Due to irreconcilable differences with hospital leadership, Dr. Ortiz was considering moving on to another practice.

Everything changed on Tuesday morning, February 7, 2017, when Steve got a phone call in the doctors’ lounge. Staff said he was white as a ghost and he must have been threatened or something. Nobody knows what happened on that phone call.

He then texted Sherry Cleveland asking for her personal email address. She thought that was strange.

That evening at 5:00 pm, he called his mother for the last time. He told her, “They are greedy; that’s all they care about.” His mom said he was very upset.

Steve Ortiz and his mom Gloria

During that 30-minute call, he shared the challenges he faced every day. His mom knew none of his struggles prior to that conversation.

He had already planned it.

On Wednesday, February 8, Sherry Cleveland got up for work shortly after 4:00 am. Though she doesn’t usually check her email, she thought Steve might have sent her something. His goodbye letter arrived at 12:09 am. She was in her bathroom getting ready for work when she read it:

Sherry was numb. In her heart she knew what it meant. But she was hoping it wasn’t true. She emailed Dr. Ortiz and asked if he was moving back to California. “Please tell me you’re okay. Please respond to me,” she wrote. Sherry wanted to call him, but was afraid she was going to wake him up. She didn’t want to wake her husband up, so she finished getting ready for work.

Sherry rushed to the hospital and pulled into the parking lot just after 5:00 am when she saw the police cars.

“I was on the phone with one of my really good friends, because I just needed to talk to someone. When I saw the lights, I was numb. I didn’t know what to think. I didn’t know what to do. I went to work that day, because I didn’t want to be alone. I didn’t want to go home and be by myself, but I really just didn’t know what to do. I was shocked because out of everyone that he worked with, everyone that he knew, I was that person that he felt comfortable enough with to share that information, and to tell me, and have me be his messenger to let everyone know that he appreciated us, and goodbye.”

Dr. Ortiz was found dead in his truck.

Wednesday morning at 2:00 am, Steve Ortiz checked in on all his patients and wrote orders to make sure they were okay. At approximately 3:00 am, he went out to the hospital parking lot where he repaired the pothole, sat down in his truck, and shot himself in the heart.

Steve’s dad and brother flew to Florida. His dad met with another doctor who said he was struggling with the same issues as his son. That doctor, like Steve, felt bullied—pulled into all sorts of illegal shenanigans that undermined the care of his patients.

In the aftermath of Steve’s suicide, flyers were taped on hospital walls naming three doctors responsible for his death and demanding justice for Dr. Ortiz. When removed, new flyers were taped back up. This continued for a month until a doctor was caught affixing them to the walls.

“He was 47 when he finished his fellowship and was very naïve having spent most of his life in school,” says his mom Gloria. “Steve was glad his training was over so he could be a real doctor. He felt alone in Florida. He had only been out of training for three years and was very disillusioned. He was not a quitter. He just could not deal with the corruption at his age.”

I first learned of Dr. Ortiz when an online Florida news headline reported a possible suicide of a local surgeon found deceased at a hospital. The article became an online tribute to Steve’s life and death with more than 155 comments from adoring patients (and curious citizens) wanting to know why a successful orthopedic surgeon would be found dead in a hospital parking lot. One woman commented:

“I called his office this morning to schedule an appointment with Dr. O. for my husband when I was told he was no longer with the practice. They would not give me any information. I found [this article] on Google just few minutes ago. If it were not for your report I would not have known. I am so saddened with this news of his loss. He was such a wonderful caring doctor.”

Others were furious with the journalist for reporting on the suicide of Dr. Ortiz: “I think it is disgraceful and disrespectful that this is blasted all over the web. This is not responsible news reporting or journalism; it is potentially hurtful gossip that has not been confirmed by any agency.”

Some argue that it is nobody’s business why Dr. Ortiz died. Others are still searching for answers years later.

The fact is without a proper investigation of his suicide, people will remain confused—many like Susan grieving in isolation.

Yet Dr. Ortiz is one of tens of thousands of doctors trapped in corrupt US health systems, caught between for-profit insurers, unethical administrators, and shareholders demanding maximum profit extraction from the sickest, most vulnerable patients. Physicians are the extraction device.

Without a proper investigation of the corruption leading to this surgeon’s suicide, there is no way to protect patients or prevent the next doctor suicide.

After posting a comment on the article, I got a call from Steve’s mom. We spoke for hours. I asked if she wanted to connect with an Emmy-winning filmmaker so her son could be honored in the forthcoming film, Do No Harm—a documentary exposing the doctor suicide crisis that ends with a scrolling list of nearly 100 names and photos of doctors we’ve lost to suicide. Dr. Steven Ortiz is now one of them.

News reports are an anomaly in the aftermath of a doctor suicide in the United States. Most are just a paragraph or two. The “article” on Dr. Ortiz was just 133 words. Reporters (as in Dr. Ortiz’s case) promise to “bring more on this story as it develops.” They never do. I have never seen a follow-up story or a detailed investigation into any of these physician suicides since I began tracking them in 2012. I now have 1,243 doctor suicides on a confidential registry—all cases that I’ve personally investigated since nobody in the media or medicine seems willing to launch an honest investigation into why so many of our doctors are dying by suicide.

High doctor suicide rates have been reported since 1858—and seem to be accelerating. Yet more than 160 years later the root causes of these suicides remain uninvestigated and unaddressed.

Of my 1,243 cases, I’ve learned that for every woman who dies by suicide in medicine, we lose four men.

Male surgeons are the second highest risk group after male anesthesiologists. Many are found dead at hospitals. Doctors jump from hospital windows or rooftops. They shoot or stab themselves in hospital parking lots. They’re found hanging in hospital chapels. Physicians often choose to die where they’ve been wounded.

Doctors choose suicide to end their pain (not because they want to die). Suicide is preventable. We can help doctors who are suffering if we stop suicide secrecy and censorship.

Medical institutions lie (or omit the truth) to cover up suicides—even when media and family report the cause of death. Instead we hear euphemisms such as “passed away unexpectedly.”

Ignoring doctor suicides leads to more doctor suicides.

Steve is just one of the 1,243 doctors I know who have died by suicide.

Sadly, the original article about his death is no longer live on the Internet.

I’m beyond appalled at the lack of investigation of these suicides.

One month after his death, Susan called the office for an appointment. “I was told that would not be possible. Then the person on the phone said, ‘He passed.’”

“Excuse me. What did you say?” asked Susan.

“Dr. Ortiz has passed away.”

“I started crying hysterically,” Susan explains. “I kept asking, ‘What happened to him?’”

“We don’t know. We think it was an accident,” the receptionist said.

Susan kept crying.

The receptionist kept saying how sorry she was.

“I found out later they lied to me. They knew what happened to my doctor. I was completely devastated that nobody called me before to let me know. I need to know what would make such a wonderful and successful doctor feel that suicide was his only way out. I don’t understand why he was put in such an awful position. People should be held responsible for what they’ve done to him. I hope they will be. I just wish that you had been around before my doctor died. I really think you could’ve helped him.”

Susan’s sentiment is shared by Steve’s mom. “Since his death I have thought several times that had he been able to go to an advocates group for help or talk to someone like you that he may have lived, but apparently there wasn’t any help available to him.”

Since 2012, I’ve offered a free physician suicide helpline. Click here for help.

Susan still remembers his final words.

During my last appointment I begged, “Please don’t ever give up on me.” He looked at me and smiled. “I won’t give up on you. I’ll be here for you.”

“When I found out about you, Dr. Wible, I was in heaven. I thought maybe I can find out what really happened to my doctor,” Susan said.

Why would such a beloved orthopedic surgeon die by suicide?

Dr. Ortiz couldn’t play the game of corruption—harming patients for profit. He asked other physicians for help—even met with the Hospital Board of Directors—and he was told he should just “go with the flow.” He sought out government officials and the FBI. He never heard back from them. He explored in his own head all the options (and documented it all). He was at a dead end. Exhausted, he saw no solution. He would rather “tap out” than play the game by someone else’s rules. He was not depressed. He was frustrated, pissed, and stuck. His suicide was well-planned. He was a truth teller and was biting his tongue just to survive. Dr. Ortiz died as a whistleblower. He gave it his best shot. He truly felt that his suicide was the only way to draw attention to—and end —the corruption.

Justice for Dr. Ortiz?

Absent an investigation by authorities, with legal repercussions and penalties, the status quo continues.

“I used to like to drive by and see Dr. Ortiz’s car in the parking lot,” says Susan. “After he died, they left his truck there for three months. People would leave flowers. Now when I drive by I can’t look at the place. I went to get my wrist looked at and It was hard being there. We would wave to each other through the glass door. I sat there and I didn’t see his smiling face. I kept looking expecting to see him. He did not deserve what he got. I am disgusted with the way this absolutely gifted surgeon was treated.”

Steve’s first wife, a fundraiser at Stanford, is trying to start a program about doctors like Steve. Medical institutions are starting to finally grasp the severity of our doctor suicide crisis.

“I don’t even do spine cases anymore, because I just can’t,” says Sherry Cleveland. “I can’t be in the room. I can’t. It hurts too bad. I see certain things or think certain things and I have to walk away, because it’s painful.”

The Do No Harm documentary honoring Dr. Steve Ortiz is now on an international film tour screening at health systems and film festivals.

I continue to investigate doctor suicides in between attending to my own patients.

As for Susan, it’s been more than two years and she still has no doctor.

In 2019, one million more Americans like Susan will wonder why they can’t see their doctor.

* * *
More investigative journalism on our physician suicide crisis by Dr. Wible:
What I’ve learned from 1,243 doctor suicides
33 orthopaedic surgeon suicides. How to prevent #34.
Award-winning NPR interview on doctor suicide
Physician Suicide Letters—Answered

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How my patients prevented my suicide (& started a medical revolution) →

Today is the anniversary of my suicide survival story—a happy ending to six weeks of unrelenting thoughts of dying when forced to see patients every ten minutes in big-box assembly-line clinics. My lifelong dream of being a trusted, loving family doc doing housecalls was gone. I saw no way out.

Until I told my patients I was suicidal.

I begged for their help. I asked them to create an ideal clinic, even write my job description. I promised to do whatever they wanted. My life sucked. I had nothing to lose. I figured we could all escape corporate medicine together. They were game.

Soon more than 100 patients delivered written testimony. I was SO excited to read it all. We adopted 90% of their amazing ideas and just one month later (with no outside funding) we opened the first ideal clinic—designed entirely by patients. Today is our 14-year anniversary of the most beautiful gift a community could ever give me—the ability to be a real doctor.

Now I do housecalls. I absolutely adore my patients. And I’ve never turned anyone away for lack of money.

Read all about how we did it here.

My patients have not only helped me, they’ve inspired hundreds of doctors to replicate our community clinic around the world. Check out the 2-minute TV clip above (& transcript below):

Pamela Wible says her parents—both physicians—advised her not to follow in their footsteps. She ignored them. But being a doctor was not what she expected. I remember one day seeing 45 patients. After six jobs in ten years, all of them in her words—assembly-line medicine—she ended up in bed seriously depressed. She had an idea—a vision of how she could save other doctors and her career. She decided to host a series of town hall meetings to let patients design her practice. Wible listened and took more than 100 pages of testimony.

Now there’s no receptionist at Dr. Wible’s office, no billing department, not even a nurse.

What do you want when you’re sick? You don’t want to park in a three-story parking garage, and you don’t want to sit in a cafeteria-style waiting room, and you don’t want to talk through bullet-proof glass when you’re sick, and you don’t want to be asked for your credit card and your insurance card and all the things that people are hassled to do when they are not feeling well.

Her overhead expenses have gone from close to 80% to 10% and that means she can afford to spend as much as an hour per visit—making her a better doctor and bringing the joy back into her job.

Wible performs minor surgery at her office and gives patients balloons and other gifts for coming in. And she sometimes barters with her patients for medical care.

“So your practice is so unique that you are exchanging this meal for surgery?”

“This meal and other meals,” Dr. Wible explains.

Wible’s ideas are starting to gain traction.

“I recently opened a clinic called Happy Doc Family Medicine. I wanted to show you around,” says Laura Knudsen, MD.

Dr. Wible is saying she can spend an hour with a patient? How many practices can do that?

She says that is what makes her happy and that’s what makes the patient happy. She says the actually can work. She’s making more money now that she was before and she is doing less work. She saves money by not having any staff. She does her billing using an online system. She says her start-up cost [for her first full year] were only about $3000 to buy the furniture and the equipment.

Meet some of the coolest doctors who have just launched ideal clinics today!

Corina Fratila MD, my favorite integrative endocrinologist in Baltimore!

Tedi Zeng, L.AC, MSOM, MBBS—fabulous doctor from China now with the most amazing acupuncture clinic in New Jersey!

Lisa Goldman, MD, offers personalized psychiatric care for the whole human in Arizona (and Tennessee)! And she specializes in helping medical students and physicians—even does housecalls!!

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

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

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

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

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

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

He replied, “Yes.”

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

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

Yes. Thank you. Exactly.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Let’s not waver on the truth.

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

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

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Living your spiritual calling in medicine →

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

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

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

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

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

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

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

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

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

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

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

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