Should pilots, doctors & truckers work 28-hour shifts? →

How long could you drive without dozing off? Maybe 8 hours? Possibly 10? How many hours do you think a long-haul trucker could drive without swerving into your lane? Would you ever want an 80,0000 pound rig coming at you with a guy behind the wheel who hadn’t slept in a day? Want to buckle yourself into your seat on a plane with a pilot cat napping on the control panel? How about a sleepy surgeon coming toward you with a scalpel? Does that seem like a good idea?

Sleep deprivation is more dangerous than working under the influence of alcohol. In fact, being awake for at least 24 hours is like having a blood alcohol content of 0.10% (higher than the legal limit in all states). Fatigue leads to car wrecks, plane crashes, and fatal medical mistakes. Thankfully, most employers have excellent safeguards so workers are well rested to prevent these catastrophes. Except for hospitals.

Today a reporter from Medical Economics interviewed me about the new debate over loosening the current work-hour restrictions for physicians-in-training. A proposal set to be finalized in the next few weeks would allow first-year residents to work shifts of up to 28 hours without sleep (as all other residents are already allowed to do) and would even allow any resident to work an unlimited number of hours without sleep without having to justify or document why they did so. I got pretty revved up so here’s a quick recap to get you up to speed.

Doctors-in-training (fresh med school grads) are called residents because they basically reside in the hospital and function as cheap labor (divide salary by hours worked and they earn less than minimum wage). Residents have traditionally worked grueling schedules with up to 72-hour shifts—or more. Though sleep deprivation is recognized as a torture technique and a violation of human rights, in medicine it’s a lifestyle, a rite of passage—even a badge of honor.

The truth is sleep-deprived residents have been running US hospitals for decades.

Until all hell broke loose in 1984 when Libby Zion (an 18-year-old college student) died in a New York hospital. Her father (a lawyer and well-connected journalist) stated, “I left her there with an earache and a fever” and “they sent her home in a box.” He soon discovered that her care was left to sleep-deprived residents without supervision. Legal battles ended with a 1989 New York Health Department requirement that doctors-in-training have adequate supervision and work no more than 24 consecutive hours with an average work week of 80 hours (rather than 100+). In 2003 the ACGME (Accreditation Council for Graduate Medical Education) applied these work-hour limits to all US residents. In 2011 ACGME capped first-year residents’ shifts at 16 hours. Note: work-hour restrictions remain unenforced in many programs (I still hear from residents who work more than 120 hours per week).

Sleep deprivation doesn’t stop after residency. One newly graduated resident was so exhausted that he developed seizures right in front of hospital administrators. Their response? Send him right back into the ICU to care for the sickest patients. Some docs are even forced to work 168-hour shifts like this physician whistleblower:

You may be wondering why residents don’t complain when their programs fail to uphold work-hour restrictions. Simple. Those who speak out face retaliation from program directors that may destroy their careers. Even worse, an investigation could result in lost accreditation for the entire residency (adversely impacting the future of all physicians in the program). So nobody says anything. Violations continue. Patients die. Physicians suffer. Some are so fatigued they die in post-call car accidents because they’re unsafe to drive home after work.

So what’s being done to improve working conditions?

Disgruntled doctors who are not “team players” are mandated to resilience training courses where they’re taught “work-life balance.” Physician “wellness” conferences and programs are popping up in every hospital where doctors are encouraged to relax and take deep breaths. Problem is meditation is not the treatment for human rights violations.

Rather than strengthen protection and enforce current work-hour caps, ACGME is discussing a return to the pre-Libby-Zion days by placing interns back on 28-hour shifts because they now believe longer hours could make patient care safer due to improved continuity with the same doctor. Yet a public opinion poll reveals 86% of Americans oppose lifting the 16-hour cap on first-year doctors.

Filmmaker Robyn Symon, producer of the forthcoming physician suicide documentary Do No Harm, personally handed a petition with more than 75,000 signatures to Thomas Nasca, M.D., the CEO of ACGME, demanding the agency take action to address the rampant human rights violations in medical training that lead to high suicide among medical students and doctors.

What other industry in the modern world requires employees to work 28-hour shifts? None that I’ve discovered. I wandered around town searching for anyone who works more than a day without sleep. I even interviewed PetSmart dog groomers to Starbucks baristas and spoke with pilots, truck drivers, and more. Here’s what I discovered.

Pilots fly a maximum of 9 hours during the day and 8 hours at night according to FAA regulations. Work week is 60 hours. They get bathroom breaks and can eat at their discretion and always have a co-pilot as backup. Truck drivers have strict hours-of-service limits as dictated by the Federal Motor Safety Administration. They can work 14 consecutive hours in which they can drive up to 11 hours. Maximum 60 hours work weeks. Bathroom breaks and meals are taken as needed.

My local PetSmart groomer works 8-hour shifts. During the holidays, she has witnessed a rare 10-hour shift. PetSmart groomers in Oregon must receive breaks per state labor laws and in my neighborhood they get two 15-min paid breaks and one 30-min unpaid break and generally work 40-hour work weeks which is considered full time. Similar story at my local Starbucks where baristas get two 10-min paid breaks and one 30-min unpaid break in an 8-hour shift during their 40-hour work weeks. Compare this with resident physicians who may work 28 (or more) hours per shift without breaks, meals, or sleep (with an 80-hour work week upheld by the honor system).

So what’s the worst case scenario if we don’t follow basic labor laws. At Starbucks maybe you’d get a bad cup of coffee. At PetSmart, Fluffy may be sent home with a bad haircut. No big deal. Right? Not exactly. My groomer explained that workers on long shifts are less likely to recognize animal distress resulting in dog and cat deaths during grooming.

If fatigued pilots have killed hundreds of passengers just by dozing off, if tired truckers have knocked out entire families on summer vacation, if overworked groomers could kill your dog, why are you placing your medical care in the hands of sleep-deprived doctors?

If you’re outraged, do something. Your apathy nearly guarantees that one day you and your loved ones will receive care from impaired doctors. Transform your rage into action. Libby Zion’s dad turned his fury over his daughter’s death into a teaching moment for the entire American medical education system. He’s dead now so he can’t protect us anymore. We have to save ourselves.

Please sign this petition to stop 28-hour shifts for our new doctors.

Sleep Deprivation Doctors

Pamela Wible, M.D., is a physician who reports on human rights violations in medicine. She is author of Physician Suicide Letters—Answered. View her TEDMED talk Why doctors kill themselves. Image credit Robyn Symon.

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My best advice for physicians in 3 minutes →

Last week I spoke at a residency retreat. A surgery resident asked for my big take-home message. Here it is (and this applies to everyone on the planet not just medical students and physicians).

https://www.youtube.com/watch?v=LIvumvFDyWw

Remember the dreams you had as a young adult. If you’re a medical student or physician, please dig out your personal statement that you wrote on the way into medical school. Read it again. Remember why it is that you’re doing all of this. They say that if you know the why you can survive almost any how (meaning you can survive almost any terrible day in the hospital or clinic if you’re fueled by your passion).

What fuels us is the image that we all had before we entered our chosen profession. When you entered surgery residency, you had a certain passion, a certain image of what you would eventually be doing. If that is serving poor people in Arkansas, please start planning how you will get to Arkansas and serve your chosen patients. If you want to do international health, start planning that now. Don’t wait until you graduate. Don’t think someone is going to come present you with your dream on a silver platter. You have to manifest your dream yourself and you’re the only one who can do it. Your residency program can’t do this for you.

Residency programs (and graduate schools of all kinds) can encourage you at intervals simply by asking, “what’s your dream?” Your advisor should ask you, “how are we doing on getting you to your goal of being a rural surgeon in Nebraska (like you said when you came in)?” I don’t think programs do this. Yet it’s so easy. And it costs nothing. 

Best Advice

My take-home message for everyone is don’t let your dreams die.

First find your own dream and start asking your colleagues, “what’s your dream?” That’s something anyone can do. Each day make it a habit to ask at least one of your colleagues, “Hey, if you could have anything when you graduate tell me what’s your dream? Tell me about your ideal practice. These conversations help us remember who we are and where we’re going in life. Plus the more people you share your dream with, the more expansive your dream will become. Need help? Contact me.

Please read “7 strategies to live your dream.” Attend our upcoming Live Your Dream Retreat for medical students and physicians. Contact Dr. Wible for scholarships.

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Ideal residency has therapy dogs, scribes & time for lunch →

Ideal Residency

I’m a fan of putting the end-user in charge. It’s an winning strategy all around. As an entrepreneur and community organizer at heart, I love bringing people together to create innovative solutions for their problems. Download MP3 and/or listen here to how it’s done (& how you can use this in your own life):

When I left assembly-line medicine in 2005, I invited my community to create their own ideal medical clinic. I collected 100 pages of testimony, adopted 90% of their feedback, and we opened one month later—with no outside funding. The first ideal clinic designed entirely by patients. Twelve years later we’re still going strong. Plus we’ve never turned anyone away for lack of money. Since opening our community clinic, I’ve helped doctors all over the country open ideal clinics too. Even helped an entire hospital system redesign themselves when I led 13 town hall meetings in 48 hours and collected 2830 pieces of qualitative data from their community. It’s so much fun! You may be thinking ideal clinics & hospitals seem too good to be true. You can do this too.  I’ll share my overall strategy (it’s simple!)  Grab a copy of my free guide to launching your ideal medical clinic here:

We all know it’s time to revamp medical education. So how do we create an ideal medical school or residency program? Put medical students and residents in charge, of course. Need help? Hey, I’d love to help your residency reinvent itself. I recently challenged 115 residents to design the first ideal residency. To encourage participation, I offered $6000 in cash & prizes. It was like the “Price Is Right” with everyone trampling each other to share their awesome ideas. Play video to see all the docs jumping over each other and piled up underneath me on the floor:

Want an ideal residency? Here’s what to do first:

1) Date night gift cards – Make a great deal with a local romantic restaurant for 50% off a bulk number of meals and then have them create gift cards to cover dinner for two. These gift cards would then be distributed to residents who have met milestones in the program so they could get to know their spouse again after being absent for a month. So simple. Right?

2) Mentorship program – Pair new residents with attendings or upper level residents who can take them under their wings. Zero cost. Lots of goodwill.

3) Mellow morning rounds – What if attendings were less “ramped up” during morning report? Try mellow Mondays. High anxiety just freaks people out and doesn’t improve learning or patient care. (People are already kinda freaked out in the hospital. Why add to the panic?) Experiment with new-and-improved teaching strategies.

4) Midday breaks – Residents would love to have some scheduled time to see the sun or walk their dogs. Possibly a 20-minute break with another resident so they could chat. One doc suggested that he could keep his pager on and just go to the gym for 30 minutes. These breaks would not count against lunch. Resident physicians would like to be able to eat lunch and see the sun on the same day. Seems reasonable. 

5) Lunchtime – Protected time for lunch that doesn’t involve lunch didactics so that doctors could have some down time to eat with mindfulness in silence.  So they can see afternoon patients with a fresh and relaxed attitude (without hypoglycemia).

6) Vegetarian food – Have a consistent vegetarian option in the cafeteria. That’s so common sense—healthy food in a health facilities like hospitals and clinics. Hey, maybe have a farmer’s market once per week in the hospital parking lot too!

7) Therapy dogs in clinic – Create a program with the local Humane Society to have an adoptable dog in the medical clinic so that doctors and patients could get pet therapy. I bet the dog would end up finding a home too!

8) Personal assistants – Assign one personal assistant for every 5-10 residents to offer household support and run errands during business hours.

9) Scribes or cap patient loads – Scribes would help residents complete chart notes allowing them to see more patients. If scribes are not possible then adjust resident patient loads to be more manageable for the safety of all involved. I bet this would reduce medical mistakes and malpractice claims too! What a winning idea.

10) Onsite childcare – One psychiatry resident shared that in her first two months of residency she only saw her daughter for six hours. We all know the deleterious impact of maternal (and paternal) deprivation. Children really do need to see their parents more than six hours per month. Right? 

11) Treehouse conference room – Maybe hold conferences outside or in some non-fluorescent less hospital-type location. I bet you would be the most popular residency in the country!

12) Leave work early – In the rare chance that residents complete work early, allow them to go home. Residents are happy to keep their pagers on if something comes up. Holding them hostage in clinic when their work is complete serves no purpose other than frustrating the trapped doctor.

13) Sharing a smile – Smiling or laughing at minimum once per day with the attending would improve morale. No cost. Simple strategy. Why not start today?

Many of these seem unbelievably simple and low cost. To achieve an ideal residency will require residents to be proactive and program directors to be open to never-tried-before ideas. Here are a few more tips for success:

How residents can create an ideal residency program:

1) Be actively engaged in improving your residency.

2) Present a complete plan to your program director (see date night example at 15:00 min on video).

3) Review the residency mission and vision statements and conform to their stated values. Use their own language.

4) Start with very simple and low-cost ideas first. Gain some momentum before going for a large overhaul.

5) Engage a champion in administration to help you.

How residency directors can create an ideal residency program:

1) Encourage residents to share their innovative ideas in an “ideal residency” brainstorming session.

2) Be open to new ideas no matter how off-the-wall and weird they may sound to you.

3) Ask residents about their dreams and how you can help them get there.

4) Pair attendings with individual residents for deep mentorship.

5) Avoid fear-based teaching with non-violent communication.

Creating an ideal residency isn’t that difficult. Maybe the ideal residency does have therapy dogs, scribes, onsite childcare, well-fed residents, and kind teachers who smile and laugh. It’s so simple really. We all want the same outcome—well-trained physicians who enjoy practicing medicine and provide great patient care. Love to hear what amazing things you do at your program. Please contact me if you need help.

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Pamela Wible, M.D., is author of Physician Suicide Letters—Answered. View her TEDMED talk Why doctors kill themselves. Ready to live your dream in medicine? Join our upcoming medical student & physician retreat. For retreat scholarships, contact Dr. Wible.

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What I say to suicidal physicians →

https://www.youtube.com/watch?v=Jmy3FLtKp7U

This week a resident asked, “What do you say to suicidal physicians?”  Great question! For an expanded version of the three simple things I say to suicidal physicians (applies to anyone who is suicidal), please listen to my podcast here and download MP3 for future reference:

1) I don’t say anything. I listen without judgement. 

Our culture doesn’t support physicians asking for help—or revealing their suffering. As a result, physicians fear sharing suicidal thoughts with friends and family because we’re the ones that others rely on for help. Physicians fear speaking to their program directors or employers because of professional retaliation and loss of licensure. Physicians fear sharing mental health struggles with colleagues due to shame, stigma, and loss of their confidentiality. If employers are notified, docs may face potential job loss or be mandated to attend Physician Health Programs (which are essentially 12-step programs for substance abuse that have turned into a dumping ground for any doc with mental health conditions). Physicians need to be able to speak confidentially to other physicians who understand their pain. So that’s what I do. I listen. Confidentially. Without judgement. For as long as they need to talk. For free As a healer and a friend.

Here are two letters I’ve received that demonstrate the need for confidential mental health care for doctors. Maria writes, “I’m having a really tough night tonight. Really just hard sometimes for me but I am happy to know that there is someone out there interested in the world, in the pain that medicine sometimes is. Rough week, lots of deaths in people less than forty.” Watching lots of people under forty die may actually lead to depression—especially when you have no opportunity to debrief from your daily trauma. So what happens when you get depressed? Amy shares her experience:

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

Yes, substance abuse and mental health struggles are late-stage consequences of inadequate emotional support for the trauma we sustain in our daily work. Blaming and shaming the victim does nothing to eradicate the underlying cause of physician mental health conditions and can even exacerbate suicide risk.

2) Then I say, “You are not alone.” 

After years of listening to suicidal and depressed physicians share their suffering with me, I’ve discovered common themes. I outline these themes in my book Physician Suicide Letters—Answered (essentially a print version of the informal physician suicide hotline I’ve ended up running out of my home). Sometimes I share my story of depression and suicide or I read letters from other doctors who have struggled due to the similar circumstances. Suffering in isolation is deadly. When physicians are suffering in isolation, they begin to feel personally defective as if they don’t belong in the profession. They may feel that their family or the world may be better off without them. When I share the common struggles of their peers, docs feel comforted. They realize that they’re not defective. They begin to understand the true origin of their suffering—an inhumane medical system that fails to provide the emotional support that any human being would require when dealing with death and suffering all day long. 

Hannah says: “Wow! I thank you for being available. Back in my worse days there was nothing on the web. I appreciate your blog. At least I know I’m not alone.” Jessica echoes her sentiment:

“After my attempt I searched and searched for any literature on near or ‘uncompleted’ suicides. I found one little book with three examples in it in my local bookstore. That was it, and my search was not limited to physician suicides. I read that book over and over. I so understood those stories. Pamela, you will be doing an invaluable thing by collecting and assembling stories of near suicides. For someone like myself, who didn’t think I was even depressed and thought I would never take my life, I had to know if there were others like me. There was something very comforting in knowing there were—even if it was only three.” 

Anna has this revelation, “I really think that connecting with you has helped me to realize it is not just me! There is nothing really wrong with me! We have been traumatized!” Many who were helped by sharing their feelings with me, then request that I share their stories to help others.

3) Finally, I say, “Call me anytime.”

I leave the door open for future communication. If I’m particularly concerned, I’ll contact them in a few days to check in. I make sure they’ve got some support (whether a close friend or a local psychiatrist). If more immediate help is required, I arrange for a Skype visit with my own therapist. In other words, we have a clear follow-up plan. Plus I invite them to join my email list so I can be an ongoing supportive presence in their lives on a weekly basis at minimum.

I’ve had no formal suicide prevention training. Just real-life experiences with hundreds of suicidal docs. Sometimes being a sacred witness to another’s suffering is all that is required. How do I know if I’m on the right track? When I read these letters: “You helped me through some of my darkest hours just by being there,” Hannah writes, “Maybe we can start a ‘save the doctors’ movement.” Karyn concurs: Thank you for being there for me and so many others in peril. Those of us who spend our lives on the edge, literally dying to heal.”

In summary it doesn’t take much more than compassion to help a colleague. I hope more people will reach out to others—whether physicians or not. Truth is we can all save lives–even without attending medical school.

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Pamela Wible, M.D., is author of Physician Suicide Letters—Answered. Please view her TEDMED talk “Why Doctors Kill Themselves.” Need help? Contact her.

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7 steps to financial freedom in 2017 →

I grew up studying my physician parents. My dad, a pathologist, was a hard-working hospital employee with multiple odd jobs on the side. He always worried about whether he’d have enough for retirement (though he never really wanted to retire). My mom, a psychiatrist, is more of an entrepreneurial businesswoman. She had her own private practice (even though all the other employed doctors warned she’d never make it going solo). Guess who earned more money? And retired early? My mom (she retired 30 years before my dad).

Pamela Wible Mom Dad

 

As a family doc in my own clinic, I do a ton of psychiatry. In fact, psychology dictates our financial success. For more than 20 years I’ve helped medical students, physicians, health professionals, and patients live their dreams and claim their value. I recently taught these 7 strategies to med students and physicians in my mentorship group. Yet they apply to everyone. This year, I invite you to share yourself with the world—and get paid! Just follow these steps . . . (listen to podcast & download MP3 below for more details).

1) Know what you’re worth. Discard the drama. Money is math problem. My mom always warned, “Don’t let your emotions hijack your clear thinking.” Given your education, your skills, and the need for your service, what are you worth per hour? What is it worth to save a life? To inspire a child? To build an organization? If you don’t know what you’re worth, nobody else will either. Trust me. Never apologize for your fees. Claim your value with confidence.

2) Release limiting beliefs. If you don’t think you’re worth much, you won’t get much. If you think more money means more work, you won’t be earning more without working more. If you think nobody will pay for your services, nobody will pay you for your services. What do you believe about money? Is what you believe attracting money or undermining your income potential? (Hint: avoid naysayers and other people with limiting beliefs. They have a way of really screwing with your mind).

3) Stop killing your best ideas. If you’ve got a great idea, get off the couch and do it. Don’t talk yourself out of the amazing contributions you were born to deliver to this world. Even worse: while you’re killing your most innovative ideas, someone else might start launching your plans. Jump up. Get moving. Don’t let anyone steal your dreams. Especially you!

4) Do what you love. When you offer your passion, energy, enthusiasm to the world, you are more likely to attract people who will value you not just for your product or service, but also for YOUR LOVE of your craft. Plus when you do what you love, you’ll never actually work another day in your life. So what’s your dream? What brings you the most joy? Now, go do it. 

5) Liberate yourself from dollars per hour. Consider charging money per outcome (for achieving a goal), money per month (like gym memberships, cell phone service, some medical clinics), money per product (book, art, speech) or per service (surgery, car repair, haircut). Money per hour will always lock you into working hourly for income. 

6) Play with revenue streams. Want to speak? Start talking. Want to write? Start writing. Have an amazing video or DVD you want to produce? What’s stopping you? Want to share your ideas with the world? Go forth and do it. Don’t forget to charge something. 

7) Start now. There is always something you can be doing at this very moment to move forward with your dreams. Whether it’s writing a book, speaking at an event, helping a child or hosting a dinner party. Invite people into your life so they can experience your passion and expertise up close and personal. Delayed gratification delays everything you want in life. Live your dream now—and fill your bank account today.

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Pamela Wible, M.D., pioneered the first ideal clinic designed by patients. She thanks her Mom and Dad for giving her the brains and the chutzpah to live her dreams—and help others do the same. Need a jolt of inspiration? Contact her.

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