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.

Human Rights Violations in Medicine—Your Survival Guide

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63 comments on “Not “burnout,” not moral injury—human rights violations
  1. Alene Nitzky says:

    The same human rights violations are killing the profession of nursing. Physicians and nurses need to support each other by fighting back against the empathy-deficient profit machines that are our healthcare system. And recognize that the patients we treat and care for are often subject to similar human rights abuses in their workplaces, and that contributes to the chronic disease burden. Thank you for calling this out.

    • Pamela Wible MD says:

      Nurses have unions and I hear there is a strike about to happen (will keep a lid on where though will be huge). Let’s hope doctors will start to follow in the footsteps of nurses and walk away from their abusers. Willing victims allow this mistreatment to continue year after year.

      • Gunther says:

        Sadly, I have seen Directors of Nursing, Chief Nurse Executives, and supervisory nurses doing everything they can to undermine the unions even though those people benefit from having a union. It is bad enough you have to deal with management who have no experience working in the trenches; however, it is even worse when you have people who have work in the trenches being promoted to managers and then turning on their own profession. They are nothing but traitors

    • Angie Chu says:

      Yes Amen to that. We operate on a multi- disciplinary team approach. Non of us could survive without supporting each other 😇🧎‍♀️🙏

  2. Anonymous resident says:

    Exactly what I’m experiencing in my residency. I didn’t understand until you put a name to it. Human rights violations!!!

  3. Diane L. says:

    Just quit my job!!!!!!!!!! Thank you. Already feel liberated.

  4. Norman Kelley says:

    You touch on a concept “sanction of the victim” identified by Ayn Rand in ATLAS SHRUGGED and developed in publication by the same title: The Sanction if the Victim. In order for any entity to succeed in promulgating such BS perpetrators must have the agreement of the people they are victimizing. You are correct in fighting this concept by exposing it. In order for the sanction of the victim to succeed, the victim must be made to feel guilty and acknowledge his guilt. Such tactic must also be exposed and fought in order to reverse the progression of the disease. I urge you to obtain a copy of the pamphlet or download it. BTW the notion of original sin is at the heart of the guilty verdict.

    • Ayn Rand Quote says:

      Sanction of the Victim: Then I saw what was wrong with the world, I saw what destroyed men and nations, and where the battle for life had to be fought. I saw that the enemy was an inverted morality—and that my sanction was its only power. I saw that evil was impotent—that evil was the irrational, the blind, the anti-real—and that the only weapon of its triumph was the willingness of the good to serve it. Just as the parasites around me were proclaiming their helpless dependence on my mind and were expecting me voluntarily to accept a slavery they had no power to enforce, just as they were counting on my self-immolation to provide them with the means of their plan—so throughout the world and throughout men’s history, in every version and form, from the extortions of loafing relatives to the atrocities of collectivized countries, it is the good, the able, the men of reason, who act as their own destroyers, who transfuse to evil the blood of their virtue and let evil transmit to them the poison of destruction, thus gaining for evil the power of survival, and for their own values—the impotence of death. I saw that there comes a point, in the defeat of any man of virtue, when his own consent is needed for evil to win—and that no manner of injury done to him by others can succeed if he chooses to withhold his consent. I saw that I could put an end to your outrages by pronouncing a single word in my mind. I pronounced it. The word was “No.”

  5. Mary Ray says:

    In internship I had to lock myself in the ER bathroom, sit on the floor and lean against the wall in order to get 15 minutes of sleep so I could function during the night shift after working all day. I could not sleep in the interns lounge on the beds because the residents would find me and make me go back to the ER to admit patients. One time in the ER I was so tired that I asked a 52 year old man how many times he had been pregnant and one time I fell asleep while talking to a patient in the ER at 5 am. We doctors, of all people should know how the human body works, sleep is a necessity….and staying up 24 hours unless assisted by legal or illegal drugs, just does not work. I did not do drugs and therefore was punished for not being able to stay up 24 hours. I would get reprimanded… doctor why is your note trailing off to nonsense? The system is constantly setting us up for failure by getting us to do things that are not humanly possible, because no one is saying anything or protesting…. that is why the suicides continue.

    • Pamela Wible MD says:

      Reprimanded for not taking stimulants? Now anyone in residency who complains risks getting a psych consult and psychotropics.

      Exactly why we need to UNITE. Nothing will get better until physicians are a unified force.

    • Pamela Wible MD says:

      Regarding: “Why can’t physicians come together on this and stand up to the abuse? Wish there were some way we could all protest our shitty working conditions and abuse in some way …… like maybe wearing black coats instead of the usual white coats to signify these dark days of medicine. I would do it. It would signal to the world and patients that we are not happy and will not wear white again until things change.”

      Absolutely anything like this could work (especially if there is visual social media appeal). They key is that ALL doctors need to do this together at your institution because otherwise the hospital will retaliate against a few. If the majority stand up, boycott, walk out, or wear black coats then THAT makes a statement that can not be buried or denied. YOU are in the power position then.

  6. Mary Ray says:

    My niece was considering medical school, I advised her to reconsider and I am happy to report she picked a different path.

  7. Henry says:

    You have the essence of the saga. The canary in the mine is sick, and it is from the toxic environment. Trying to teach it yoga and breathing exercises will not help. It is like putting sugar in the cup of hemlock.

    • Pamela Wible MD says:

      For doctors who are so concerned about having the definitive diagnosis, I would think that we could be very
      clear about what is going on—with a solution-focus.

      Again, we can’t solve a system emergency that requires primary prevention by labeling victims with
      some lees-than-accurate terms and trying an array of tertiary prevention strategies that have failed.

      Time for the truth—and action.

      ~ Pamela

  8. Lisa says:

    The hospitalists in my hospital have 18 patients assigned to them.

  9. Kate Mayes says:

    Wonder what would happen if the state medical boards began to work to protect the rights of the people? ALL people.

    Including doctors.

    Follow the money.

    Who runs the recovery programs for physicians?
    South Carolina
    North Carolina

    Anyone else out there want to weigh in on how their state medical boards are helping? A trust of great mentors.

  10. Shalena Garza says:

    Anesthesiologists are also more likely to be disciplined by medical boards. I think this is not an effect but a cause. Its out of control with these Boards…Because they are given a window to violate constitutional rights which is suppose to be “narrowly construed” but inch by inch they have ignored the line because no one is watching them but the special interest groups who want to discipline doctors “The Doctor Haters” I call them. I have had contact. They are people who do not care about the quality of work that the Boards do, they only care about discipline of more doctors. The mindset is in the opposite direction of progression for the better interest of society. The direction should be more toward education and training of physicians who make mistakes and healing of those who suffered due to those mistakes. It should include the second victim who is the doctor who made a mistake also. The only time a lawyer should be involved is when there is obvious criminal activity. The claim that the Board actions are not discipline but they are nothing but discipline and its pretty extensive.. They treat them like criminals… Even I felt like a criminal and even if the accusations against me were true, its fucking academic! The probation departments use ex-cops. Dirty ones. The goal is to discipline doctors. The Boards are brainwashed and whenever something is a stark violation of the doctors rights as a human being the Board replies with the same sentence..’Whenever there appears to be a conflict between the right of the individual and public protection, protection shall be paramount’. So that is their motto I say “protection shall be paramount”. Its the brainwashing phrase used to justify violating human rights for the greater good. But since doctors are a minority, they just get annihilated one by one. Oh and then there are the expert witnesses… talk about pitting us against each other….just like in med school and residency as you described Pamela. (I watched your video, I love you!) The med boards are like the ultimate bully. Our entire population of physicians is under the control of an abusive and controlling regime. We have to take control of our own profession in the legal sphere. Most doctors are not aware of the extent to which this “protection shall be paramount” has gone off the rails. Or maybe they hear horrible stories and just stuff it away in the mind with all the other trauma. The Boards have created laws which are in stark violation of the constitution just so it is easier to discipline doctors and then prevent them from appealing in higher courts. Whatever it takes to make the process of disciplining doctors streamlined, they make it happen. Oh and they are hiding that they discipline more females… I know it. The males are more likely to be disciplined for sexual behaviors so if you control for that, you will find females are more likely to be disciplined. It is because the Boards are so far off the rails that they actually discipline after believing negative performance evaluation comments and criticism of personality traits…the very issues we must confront as women in performance evaluations that is finally starting to come to light now. I knew it in my heart. I knew it. This was the basis of my research you know…my hypothesis that I knew had to be there but somehow I doubted myself because I had no proof elsewhere. It was just that occasionally someone wrote something that was completely off and insulted my level of understanding and I knew it…so I had to find out….Why would that person think I did not understand? Is it my appearance, my voice, my demeanor? I had theories but I just kept it to myself thinking well maybe I am sometimes…but then knowing I wasn’t. Frustration. Some were just obvious bullies. I was able to separate what I call “non-constructive” criticism from constructive. So then if you reject the “non-constructive” criticism the evil ones say you have a problem with “accepting feedback”. But women are less likely to receive constructive feedback. I think some people just do not realize the inherent bias in evaluation of females during medical school and residency. Anyway,the Board is hiding the statistics of the demographic study that was done a few years ago. If they were not hiding it then they would have easily reported gender along with their report on race disparity. They only reported race and then the rest of the data is “confidential”. There is so much more to be revealed in that data. What is also a horrible trend is that the Board is publishing everything in order to increase public awareness but the documents are one sided! Selective transparency is not public awareness, its deception! In addition, they are forcing doctors on probation to tell their patients now that they are on probation! Yes with a sign on the wall or something, a notification during check in! By bruit force “The Doctor Haters” have been pushing for that fiercely. But the public cannot see the raw data of the results of the demographic study because its “confidential”? ….I think the Board members, investigators,prosecutors and doctor haters should all undergo extensive personality and mental health exams and then the public should be able to view those reports right there next to their name and photograph via a link on the Boards website! Isn’t that a great idea? I think its a great idea..oh and we should publish their home addresses too unless they can purchase a PO box. We should force them to take IQ tests and publish those also. I think the ACGME is hiding gender discrimination now too. They have “engendered” a problem and they do not want to cause mass hysteria by publishing it. How can that phenomenon only be found in the specialty of ER? And how can these insulting comments only be found in evaluation comments in other fields? They are hiding it. Women are evaluated in performance evaluations using terms that are insulting of intelligence and less often helpful and often critical of perceived masculine traits and then the medical board is disciplining women or denying licenses based on those stupid residency evaluation comments. Okay yeah….I went on a tangent…… so what!…. My point is that I think medical boards are contributing to the suicide rate because instead of moving toward change based on intelligent progressive thinking, they are being forced to move in the opposite direction based on political pressure of special interest groups.

    • Pamela Wible MD says:

      Yes, I’ve seen what you describe. Those is toxic systems who are not “team players” are heavily punished for speaking the truth. Entire broken medical system requires FEARFUL and ISOLATED doctors to perpetuate the cycle of abuse. Just gets passed down from generation to generation. We really could solve this.

    • Danielle Murstein, MD says:

      I totally agree that there is a great deal of unconscious (and sometimes even deliberate) gender bias in evaluations of women, by both women and men, actually. I have certainly both seen and experienced this multiple times in multiple positions, with intelligent and outspoken women often the most targeted.

      The system is unfair, and beset by numerous biases, racial, gender, religion, and many others. The question is, how to reform the system? Who gets on the Boards and why? I hadn’t heard about the ex-police officers being the probation officers, but that would clearly contribute to branding the MD as a criminal. Your sentence, “The only time a lawyer should be involved is when there is obvious criminal activity,” is absolutely correct. The statistics on how many MD’s are sanctioned or otherwise dealt with by Boards should be open and discussed in MD professional meetings, with the goals of helping each other do better, in a fair manner.

      The doctors I’ve spoken with, admittedly few, who have had run ins with Medical Boards, felt targeted and felt that the punishment far exceeded the crime, so to speak, and when I heard the hoops they had to jump through, at their own expense (excessive drug testing, etc), I had to agree. Unlike police and firefighters, MD’s have not truly had each other’s backs, especially during training.

      Human rights violations is the correct term for the unrealistic hours expectations, brutal conditions with no time to use the bathroom or connect with a loved one for a few minutes by phone, no time to shower, etc. Being treated as a criminal by the Boards, while being publicly humiliated, is the last straw.

      No wonder there is an ever increasing shortage of MD’s and doctors are retiring early in droves. We need a way to communicate these issues, and find solutions, in a way that safeguards the public without killing the physician…

  11. Don Stewart says:

    I walked away from the hospital in 1986, the day I earned my license to practice medicine. Earlier in my intern year, one of my ‘mentors’ berated me with the phrase, “You’re supposed to be smart, but you’re certainly not showing that here… You may not be cut out to be a surgeon.” I don’t know why that particular round of derision struck me differently than any other (perhaps the pun of ‘not cut out to be a surgeon’ hit my funny bone, and woke me up), but my response was refreshing: “If I’m incompetent, that means I’m putting your patients at risk, and that runs counter to my Hippocratic Oath. I therefore have no choice but to resign.”

    Ironically, there followed a hastily organized effort to keep me on staff for the rest of the year (apparently I was not completely incompetent after all), but that was all I could take. I left my medical calling for humor and art, and am happy to report a thriving practice of elevating endorphin levels on a grand scale.

    Decades later, a dear friend and Vietnam veteran diagnosed my persistent, occasional flares of anxiety and anger as PTSD – something I didn’t believe I had the right to claim given my privileged academic experience. Thank you for putting that experience in its proper perspective.

  12. Resident with intermittent SI says:

    I’m very much in agreement with your exposure and assessment of the problem. I’m about to complete residency; I have fallen victim to “burnout” in that I resorted to self destructive health behaviors, and ultimately, during a period of time in my second year, I nearly lost my marriage as a result of my toxic job environment and my inability to grow robotically resilient in response to growing problems at work. I was suicidal for about 2-3 months. I got therapy, it helped, I grew past it. I’m still paying consequences professionally for the period of time I was homeless and suicidal, and my graduation is at risk because of this period of abject “failure” to deal with the gross reality of resident life. Thank you for what you do, it will be immensely helpful to further band together and expose the issues needed

    • Pamela Wible MD says:

      Wow. So glad you survived. Did you have mental health issues before medical training? Just curious . . .

  13. Amna MD says:

    Isn’t working 36 hours continually human rights violation?

  14. Rodger K Bufford says:

    If moral injury is the problem, what are the events that cause it? What steps can realistically be taken to address it?
    It seems that the problem becomes greater as medical systems grow larger, policies and regulations become more constraining, and financial and other incentives to resist change grow. Sadly, while putting the government in charge may solve some problems, most of these will likely both grow larger and become more intractable.
    So what do we do to fix all this?

    • Pamela Wible MD says:

      Moral injury is downwind of a system that allows human rights violations to persist in training and beyond. Forcing caring sensitive brilliant existential thinkers to see human suffering all day—in seven-minute increments (assembly-line medicine)—without any on-the-job mental health support is pretty much a recipe for disaster.

      So what do we do to fix all this?

      Free resources here:

      What physicians need now

      Protection by labor laws standard in other industries including mandatory meal and bathroom breaks

      Protection by the Americans with Disabilities Act including immediate removal of invasive mental health questions on applications for state licensure, hospital privileges, and insurance credentialing.

      Access to non-punitive mental health care to prevent occupationally induced lifelong mental health sequelae from chronic exposure to death and suffering.

      Protection under the Unites States Constitution that guarantees freedom of speech and a right to peacefully assemble—especially in the aftermath of a physician suicide.

  15. MF says:

    Is it a human rights violation when we voluntarily subject ourselves to the abuse in exchange for the money?

    Just asking.


  16. Integrative Doc says:

    Oh my gosh! He used your term? I love the way you describe it by the way!

    • Pamela Wible MD says:

      Imitation is the best flattery. I’ll go with that over intellectual property theft. I’m just glad the rally cry is spreading. We need many voices. Many megaphones. Grateful people are waking up from the slumber.

      Repeating physician “burnout” over and over again for 40 years has a sedative effect. Kind of makes one’s eyes glaze over.

  17. Donna says:

    Wow that’s scary.

    • Pamela Wible MD says:

      Ya. I knew something was wrong in the house of medicine within a few months of starting medical school in 1986.

  18. Eric says:

    You had me up until you recommended unionizing. While I would once have agreed with you, a lecture by a medical ethicist changed my mind. I can’t do his in-depth talk justice in this space, but he made many good points, including about how the “union mentality” affects groups, causing them to protect their own to the detriment of all others. For examples, just look at other professional organizations that have unionized
    -Teachers will strike mid-year, knowing that by harming students they can bring pressure to bear on legislatures. They also protect not only incompetent teachers, but even sexual predators in some cases (they have a term in education for allowing bad teachers to resign rather than face discipline or criminal charges: “Passing the trash,” because they know the bad teachers will go on to work in another district.)
    -Federal employees are protected so well by their union that it’s almost a national joke that they can’t be fired, no matter how incompetent, insubordinate, wasteful of taxpayer dollars, etc.; even those who commit felonies on the job are vigorously defended and collect pay and benefits for months or years before they can be terminated.
    -Police unions will protect their own no matter what. Not only do they protect the dangerously incompetent officers from discipline or termination, they shield bullies, racists, criminals, and even murderers within their ranks (as countless news stories in recent years have shown us).
    And frankly, given how the rank-and-file physicians have been abandoned by the AMA, the AAFP, and other organizations that are supposed to represent our interests, I’m not confident that a union would really stand up for the issues I’m concerned about anyway.
    I don’t have all the answers to the abuse of residents and employed physicians. But I do know that unionizing will have unintended, negative consequences, both for our profession and our patients.

    • Pamela Wible MD says:

      Isolation isn’t the solution. Uniting in some fashion is. Any such thing as a healthy non-dysfunctional union? Or maybe dysfunctional people end up in dysfunctional unions? Would have love to hear the lecture. There is probably not one way to unionize.

      • Doc says:

        I have now been practicing medicine for about 7 years. But still have what I call post traumatic stress disorder from my residency program.

        I remember being up from 8 AM one day until 5 PM the next day with no sleep and very little food or water. I was exhausted and remember people berating me, bullying me and questioning my competence, intelligence, etc.

        I survived and my moto was, never let them see you crack. Unfortunately, the people that showed weakness were even worst targets of bullying and intimidation. When I became a senior resident, I was always trying to protect the juniors from the attendings. One attending was upset that my residents seemed happy. As if learning and working were incompatible with happiness.

        But somehow, I am ashamed to report, that I feel I am part of the problem. While, I, have never bullied or intimidated anyone, I somehow became programmed to think that those who had nervous breakdowns were somehow not cut for medicine. Thank you, for stating the obvious.

        • Pamela Wible MD says:

          We all have the potential to become abusers (or complicit in the abuse) once we are victims. It’s a cycle. Medicine is an apprenticeship. We recreate what we’ve been taught. Insight is the first step to behavior change. Thanks for your honesty.

    • David says:

      Could not agree more. I used to feel sorry for teachers, but have come to realize that they chose to be teachers knowing what the conditions and pay were going to be ahead of time, but now go on strike frequently for better pay and benefits and hold our children hostage, all the while saying that they are striking for the good of their students. What a load of bullshit. I would be very mistrustful of a doctor’s union. It always seems that the people who seek positions of power in unions (and organized medicine) are the very ones who should NOT be in those positions. I do agree with a doctor’s strike or walkout, however. Doctors have a huge amount of power over the entire system. No one can sub in for them, therefore a walkout would immediately force a hospital, insurance company, or state legislature to acquiesce. The problem is that doctors are too timid and lack the backbone to do something like that. I know, I’ve tried to organize my colleagues at one of the hospitals that I work at. I gave an impassioned speech during a medical staff meeting with the entire administration staff present. Things like forced EMR compliance/training on our own time, forced MOC and recertification, bylaws changes not in physicians’ interests, etc. Not a single doctor would support me, but several little toadies spoke up in defense of the hospital. After the meeting, some of the medical staff approached me and told me how they agreed with what I said, but were scared to say anything. Nothing will change until we can stop being scared.

  19. JM says:

    Thank you so much for this. Received at a time when I feel up against a wall trying to fight for the acknowledgement that the system needs to change . . .

    • Pamela Wible MD says:

      First step is telling the truth. I think we are getting close.

    • Pamela Wible MD says:

      Feel free to spread the good news. And the solutions are actually not that challenging to enact.

      Protection by labor laws standard in other industries including mandatory meal and bathroom breaks

      Protection by the Americans with Disabilities Act including immediate removal of invasive mental health questions on applications for state licensure, hospital privileges, and insurance credentialing.

      Access to non-punitive mental health care to prevent occupationally induced lifelong mental health sequelae from chronic exposure to death and suffering.

      Protection under the Unites States Constitution that guarantees freedom of speech and a right to peacefully assemble—especially in the aftermath of a physician suicide.

  20. Cory says:

    I have been a nurse for 49 years. Substitute physician for nurse and you have the same situation. Thing were a lot better before private profit healthcare systems. Making a profit on people’s illnesses is immoral but most of the hospitals today are more concerned with making a profit than properly staffing physicians and nurses. Extra staff takes from the profit. Do away with for profit hospitals and I guarantee things will improve.

    • Anthony Patterson MD says:

      Historically, the problem is not “for profit” but “corporate.” In my home town, there was a hospital owned by a single physician until his retirement. He was happy, the nurses and other staff were happy, and the patients were delighted with his care — admittedly pre-1970, but still. He worked for a profit. Corporate hospitals are owned by impersonal Artificial Persons (the technical, legal definition of “corporation”. I suggest it is precisely that impersonal, impersonal/depersonalizing factor that just might be at the core of all that is wrong with medical education and indeed healthcare in general! After all, what is a HUMAN Rights violation to an Artificial Person?

  21. MFM says:

    I would say it is more like a blend of prostitution and Stockholm Syndrome 🙂

    Have a nice day.

  22. Jim says:

    What bothers me most in medicine is that patients are always at the bottom of the totem pole whereas money is always at the top. Those who are rewarded in medicine are those who build the upside down totem poles. Day after day I see it. My colleagues who see 80 patients in a day are thriving. On the other hand, I’m struggling to keep myself in the game. I spend time with my patients and am subsequently financially punished for doing so. I enjoy the time with my patients and beam when I’m complemented on my style of practice, but my heart is no longer in it. I stand by my principles only to then struggle, emotionally, physically and financially. I suffer from moral injury. I witness betrayal of what’s right (proper patient care) by legitimate authorities (most of my colleagues) in a high stakes situation (health of patients). Patients’ human rights are being violated.

    • Pamela Wible MD says:

      Have you thought of disintermediating your practice? Removing no-value-added intermediaries that are profiteering passively off your revenue generation?

  23. Julian says:

    Your take on the problem seems to me right on target. Getting its urgency recognized and making the systemic changes needed won’t be easy, but I hope you and others in your generation can get it to happen. What follows is an octogenarian’s comment on a minor issue, one which obviously also interests you: the origin of the term “burnout.” You trace it to 1970s slang for end-stage drug addiction, and from there to Freudenberger’s 1974 article on occupational burnout. In fact, the term originated much earlier.
    The Wikipedia article on Freudenberger, to which you provide a link, in turn has a link to one on occupational burnout. The author of that article mentions a 1961 book by Graham Greene, “A Burnt-out Case,” and cautiously suggests that “the phrase may have been in use outside the psychology literature before Freudenberger employed it.”
    In fact, Greene wrote his novel after visiting numerous leprosariums, where the term “burnt-out case” had long been in use as medical jargon indicating end-stage Hansen’s disease. In the novel, the term is extended to the mental and moral exhaustion of the protagonist, a “burnt-out” famous architect. So Greene’s analogical adaptation anticipates Freudenberger’s by more than a decade, and the term as applied to Hansen’s disease long antedates the drug-addiction slang.
    Greene’s book had very extensive exposure. Time magazine’s reviewer called it Greene’s greatest novel, and many other reviewers concurred. As for the term “burnt-out,” the blurb for the seventh soft-cover printing (1967) does not even mention the original meaning of end-stage Hansen’s disease, stating simply that the protagonist’s “soul was burnt-out.” If that suggests that by then this analogical use of the term was quite current, I can attest to that from personal experience. No doubt some industrious graduate student could examine the appropriate corpuses of oral and written English and publish a paper demonstrating it. The application to end-stage drug-addiction would hardly be a surprise.

    • Pamela Wible MD says:

      Aha! Yes, I am familiar with that other use of the term for end-stage Hansen’s disease. Curious if that author used it in isolation or was it used by others. Love to know more about the origins of words. Fascinating. Thanks for your wisdom Julian.

      • Julian says:

        You’re welcome. It would seem that at least in the leprosariums Greene visited the term was in common use.

  24. Jamal Hussain says:

    It’s not just the work place that leads to physicians despair , the whole medical industry and regulations and even patients expectations make it difficult to satisfactorily work and come home. There r too much unreasonable expectations placed on us and the space to fulfil them is getting narrower everyday. We r made responsible and answerable for things that no other profession faces. There is no neutral actor towards physician.

  25. Casey-Lee says:


    I am a Registered Nurse that has survived what I call burnout (still experiencing the long term effects). I am branching out into creating my own integrative medicine program for medical professionals that fosters holistic self-care. I watched your video on burnout and how it isn’t an accurate term to be used at all. I agree doctors and nurses suffer human rights violations all the time and it should not be minimized, covered up or blamed on the victims! I am a Nurse Coach and the part of your video about the burnout coaches struck a chord with me. Any recommendations to make sure my medical family knows that is not me! I want to really help and support those suffering?

    I hope this makes sense Dr. Wible.



  26. YJ says:

    Thank you Pamela Wible, and everyone else who do all they can to get the word out and those who strive to continue care under these barbaric conditions. When this healthcare systems in all its awful parts, force doctors to “perform” this way, they not only kill the abilities of, as well as, the doctors, but the system is also killing us patients. My health will kill me, and not soon enough, as a direct result of the suffering and further damage done to my body, not by doctors who don’t know, but by a system that REFUSES to let them do their job! I realized this years ago, FINALLY found my own answers that were INHERITED (a few inherited conditions) and should’ve been diagnosed years ago-not in my late 40s!-by my own research, all because doctors weren’t allowed to even try to help. I’ve lost everything including the will to live, and this medical system has everything to do with it. Fortunately, by my own research, I was able to discard the lesser possibilities, focus my research on the actual conditions, one by one, and with professional help (to their risk), get to a middle eastern country where the doctors are allowed to search for the right dx and do whatever help they can, even though they all say its too late to help me with my zebra and even horse conditions. If I hadn’t listened to my body and stopped taking all the drugs the system hands out-instead of letting you search for answers or even listen to more than one symptom each visit (and I do KNOW that it is the companies’ fault, NOT the loooonnnnnng list of doctors that I’ve seen in the US over the years) the shelf full of meds they gave me just trying to guess in their five minutes of seeing me would’ve had me dead decades ago, and they still might due to the damage to liver they’ve caused by tying ALL the doctors hands and only allowing NPs to see zebras that come into their office (again, always knew this wasn’t their fault either and I’ve been told by faculty and supervisors what the policies actually are) My first genetic condition that I had to find myself, and was later finally confirmed after I got a specialist who would actually see me though that was precious few years ago-since then, I’ve gotten the rest of the dx that I needed, but again, only by my research, help from other zebras then finally the right tests here in the middle east (yes, I also get denied care from specialists because of my long lists of proven diagnoses, as my first genetic condition affects every organ and tissue in the body because the cells don’t have the right “glue” to hold them together, the rest is taken out by multiple ANS issues and neuropathy issues, which all got extreme within just a few years of each other, again, due to the medical system’s rules, not doctor deficiencies…and yes, at least one of my regular doctors did succeed at suicide three days after I saw him) I dance with the dragons daily and am fortuante to only almost died four times.
    Keep up the good work, you doctor survivors! What you learn, what doctors around the world learn and try to live up to, even when they don’t/can’t get the same training as you, allows them to at least try to save the ones that are on Medicaid, medicare, no insurance, etc. that America won’t allow you to save. Here, they have the time to listen, though they still work long hours at both the public hospital (required for all of them) then have their own private office in the evening (they can’t even start there until about 7PM, but I am so thankful that they do what they can!) Even if you don’t feel your patients benefit, please keep in mind that EVERYTHING that you tell a patient about what you even THINK, even if its that you don’t know but you’re trying, is WORTH EVERY SYLLABLE to the support and will to live of the patient-especially us zebras!- and your “simple” words might be the difference between their suicide and their continued fight to live. You all should also know that all the info that you give a patient, in each and every word, is used by us zebras-that you don’t even know are zebras-to help us put that together with our own research and zebra community to help other zebra patients all around the nation and indeed the world. You are helping worldwide just by giving your thoughts to a patient. Even just validation means so much to our struggle for answers! Get rid of munchousen and keep us alive. In time, we may find the answers that you were not allowed to find, and we’ll be back to YOU to get the tests that confirm and help us! The biggest help in both discovering (yes, after months and months of guided research, we ALL go to you doctors with our info to ask for the right tests to rule out or confirm our suspicions. Stop criticizing google searches! These are the only reason that we zebras are still alive or ever get the right diagnoses! We don’t want to challenge you, we are begging for your help because we can SEE that your hands are tied tightly. When we search online, it is NOT because we enjoy the long hours of reading studies, reports, definitions of terms, etc. its because we are DESPERATE to stay alive or at least manage our symptoms better because for zebras, we are usually way past the published medical, day to day, common advice but with the right dx, we can understand our bodies better to find creative ways to manage our symptoms and make life (possibly) worth continuing which is not in the medical information but we share with, and benefit, other zebras.
    Please don’t give up on us! Spread the word of the truth of the medical system, don’t leave us, open a private practice even if you can’t see us in the hospitals (yes, we know how that works too) advertize on zebra sites and social media that you are your own bosses and well will come! We also have “big mouths” and the ability to advertise you (and we do) so PLEASE, don’t give up, just change what you can then let us know and help you be viable! PLEASE, on behalf of the whole zebra and other medical communities, make the change, we WANT YOU! We don’t even care if you know about our rare conditions, only that you are willing to work with us, your pride won’t keep you from at least trying on what seems impossible, and that you will validate our life, even when you just admit that you don’t know but are willing to listen and explore the possibilities that we suggest. We can actually tell the difference in a difficulty to breathe caused by FMS/CFS EDS or actual bloodclots, even though there are no real words to describe to a “normal” the difference between the muscles/tendons being to weak to breathe, being to “fatigued” to breathe, “forgetting” to breathe or not being “able” to breathe because of blood clots. The few minutes in the office isn’t enough to understand us, but if you let us, we will help you understand by researching-and mostly discarding-the possibilities of our problems! Please help us stay alive and maybe you’ll even help up to “live”. Thank you. (sorry, not going to proof any of this again, I hope is makes sense. Can’t regain any more health than this for proofing again.)

  27. Jamie Leavitt says:

    Social workers and mental health providers are here as well. I am taking a medical leave for MDD because I am injured. I have been in practice as a LCSW for over 20 years. The past 5 in health care. I am in tremendous pain, my cognitive functioning declined and my spirit crushed under the truth of what patients face when they go for help, healing, and pain relief. They are often met with judgment, ridicule, standard procedure and misdiagnosis. They are lying on gurneys in the hallways of the ED awaiting… and while they wait, their torment, fear and hopelessness are fed.

    Structural barriers and taxing demands on providrs are not addressed. We are crushed under it and not even supporting each other to the level of truth because WE NEED THE MONEY AND OUR JOBS TO SUPPORT OUR FAMILIES WHO ARE ALSO SUFFERING BECAUSE THEY FEEL OUR STRESS! It’s not working And we are dropping because we feel like failures!!! But we are not failures at all, we are the ones who are seeing the truth.

    I am grateful for a place to write where someone may read and understand. I met an NP in my providers office to begin treatment for my condition. She listened, she heard, and she knows about moral injury and human rights violations. She said it before I, and thus validated me. It may have saved my life as it lifted the shame enough to breathe. Thank you KS.
    Keep the conversations going and PLEASE ADD SOCIAL WORK AND MENTAL HEALTH PROVIDERS. ESSENTILY WE ARE PHYSICIANS and we suffer human right violations daily. No More…

  28. Jose Orozco says:

    Thank you for such a great website, and for calling attention to such an important issuue that is being ignored. However, I find that you hardly mention what I consider to be the biggest issue – the threat of a major lawsuit. One lawsuit can destroy the career and ruin the finances of any physician. Lawsuits have little to do with medical facts and are frequently based on patient financial need or dislike of the physician. On my 20 minute drive to work this morning, I passed 11 billboards urging patients to sue a doctor.

    I have seen colleagues sued for the most absurd things, including one who was sued for the side effects of a medication that he did not prescribe.

    The long hours and the stress of critical decisions do not affect me like the constant threat of lawsuits. With lawyers controlling our government, I do not see that changing anytime soon.

  29. Gregory Av says:

    I am a US graduates,a month ago I was PGY2 IM resident physician at program MS,when DIO and program director just throw me and my family including my 2 minor kids 7yo and 4 yo , only because some one sad that I was not good listener,or i was not good a team player.,or I had an accent….This is Horrible ,Unfair!!!!!!!!!!
    When PD protecting his wife who is a PGY1 at same program with all favoritism including special treat rotations and all that….When we as a society besides fighting illegal immigration or fighting for healthy air ,when we actually address and brake that corruption in medical residency areas!!!!!!Speaking of Discrimination,humiliation ,verbal abuse to name a few. I believe that is symptoms of violation of our constitution ,violation of human rights.

  30. Anonymous says:

    Worst when you get sick with COVID and loosing your PTO, because of it.

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