Physician, First Do No Harm—To Yourself

A psychiatrist in Seattle had picked out the bridge. At 3 a.m. he would swerve across his lane and plunge into the water. Everyone would assume he fell asleep.

A surgeon in Oregon was lying on the floor of her office with a scalpel. Nobody would find her until it was too late.

An internal medicine resident in Atlanta heard an anesthesiologist joking about the lethal dose of sodium thiopental. Alone in the call room, she would overdose that night.

Three planned suicides. All three physicians survived. Why?

While preparing to overdose, the internist was interrupted by an endocrinologist calling to check on her. Before grabbing her scalpel, the surgeon called several physicians pleading for help—I responded immediately. Two days before he was to drive off the bridge, the psychiatrist spotted my ad for a physician retreat. He called me begging to attend.

One week later, I’m hiking through the Oregon Cascades. The scent of cedar envelops me as I approach the lodge where I’m welcoming physicians who have arrived from all over the United States and Canada, all of us on a pilgrimage for answers.

Tonight we begin a retreat for doctors who yearn to love medicine again. Studies confirm most doctors are overworked, exhausted, or depressed. The tragedy: few seek help.

I ask the group, “How many physicians have lost a colleague to suicide?” All hands are raised. “How many have considered suicide?” Except for one woman, all hands remain up—including mine.

“Physicians have the highest suicide rate of any profession,” I explain. “In the United States we lose over 400 physicians per year to suicide. That’s the equivalent of an entire medical school. Even that’s an underestimate because many physician suicides are incorrectly identified as accidents.”

I tell them, “Both men I dated in med school are dead. Brilliant physicians. Loved by their families and patients. Both died young—by ‘accidental overdose.’ Really? How many physicians accidentally overdose?”

The room is quiet.

It’s easier to say accident than suicide. Doctors can say gonorrhea and carcinoma. Why not suicide? Maybe we can’t face our own wounds.

“I’m a family doc in Eugene, Oregon, where we’ve lost three physicians in eighteen months to suicide. I was suicidal once. Assembly-line medicine was killing me. Too many patients and not enough time sets us up for failure. Rather than kill myself, I invited my patients to help me design an ‘ideal clinic.’ It is possible to love medicine again.”

The Canadian doctor to my right wipes her eyes. “I’m feeling so discouraged. I want to give up and work at Starbucks. My head is exploding from banging it against the system.”

A bright-eyed, blonde woman reveals, “I just took a leave of absence from med school because it was ‘killing my soul.’ Three classmates attempted suicide.”

A newlywed couple join in. “I’m a nurse. My husband is an internist. He’s suffering, but I don’t know how to help him. Doctors don’t seek psychiatric care because mental illness is reportable to the medical board. He fears he’ll lose his license.” Her husband adds, “I was suicidal three months ago. On the edge. My wife and I are hoping to find answers here.”

Here, physicians, nurses, and medical students share their wounds and their wisdom—in community. We share new practice models, communication techniques, and strategies to care for ourselves—so we can care for our patients.

In four days, I witness more healing than in four years of med school. Once strangers, we’ve become family. Parting ways, the psychiatrist from Seattle thanks me again.

I didn’t know these doctors, but I know their despair. By speaking about my own pain, I validated their pain. By being vulnerable, I gave them the strength to be vulnerable too.

But mostly we healed each other by not being afraid to say the word suicide out loud.

physician-suicide

Pamela Wible, M.D., is a family physician, author, and expert in physician suicide prevention. She offers biannual retreats for physicians struggling with burnout and depression. Contact her at idealmedicalcare.org.

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22 comments on “Physician, First Do No Harm—To Yourself
  1. Lynda M O says:

    Thank you for the help you give to other medical folks who have the hardest jobs anywhere. I love my doctor and I am afraid that she will burn out; she’s got two young kids and took a year off to medical leave that just finished less than a year ago. She seems overwhelmed when I see her every couple months for my med refills.

    Keep up the good works and please please please take care of yourself first.

    • Pamela Wible MD says:

      Thanks Linda! I am taking care of myself. Going to the kitchen to make a kale smoothie right now! Thanks for the reminder. We all need to take care of each other. Really. Hey, happy to give you and your doc a copy of my book – will cheer her soul!!! Or you can get it on Amazon. A GREAT gift for a great doctor: http://www.petgoatsandpapsmears.com/

      Thank YOU for caring!

      XOXO

      <3 Pamela

  2. DE Tedoru says:

    My father was a physician and a scientist. I was too. But just as neurobiology was a total mystery to him, molecular biology was a total mystery to my medical generation, so much so I had to retire to study it. Does that matter? Can an MD get by doing those Pharma CMEs where large group studies are done; to which the MD only lends his/her name, the paper is written by a composition company, the statistics are done by the drug company’s statisticians and, most likely the original author probably never read “his/her” own paper with his/her own name on it?

    Most of us worked hard every day trying to hone the fine line between the roles of spiritual adviser and healer of the patients assign us– neither of which we can do very well. We abide by the algorithms imposed on us by the analysis of the above type of studies that the Institute of Medicine imposes on us via fees-for-service payments categories (one-size-fits-all) imposed by Medicare/Medicaid and insurers. We do our requisite CME credits per year but otherwise we function ignorant of why “this way, not that way, is it.” Medical School was Hell, residency was super-Hell and then…BOOM!…out you go into private practice or into a salaried job like 80% of physicians– all identified as to year of graduation by how he/she practices. Anyway, you hit 50 and wonder: IS THIS ALL THERE IS?

    One should not confuse a profession with a vocation. MEDICINE IS NOT A PROFESSION IT IS A VOCATION; it is total warfare with death and suffering, where you are outnumbered 2-1. And then, sneaking up behind you is another foe: “AM I MAKING A MISTAKE?” Fear of mistake makes it 3-1! So often I heard since medschool: “a good clinician is the guy who gets it without thinking,” as if the superior sub-conscious brain circuits are far, far better at problem solving that the verbalizing “thinking brain.” Do we all remember bedside clerkship years where the coordinator hit us with spot questions or the surgeon demanded minute anatomic landmark questions?

    All that and more we survived and here we are swamped: Dx, Rx/Tx almost like a coin toss, protected from lawsuit only by “standard practices.” But is that the so high capitation “medicine”– where you get about ten minutes with a patient– what we strived for all these years? The doctor-patient relation of today is more like that between a John and a prostitute rather than like that in a marital or life-long partnership of a team fighting death, suffering and mistake as 2 to 3. The individualization of patients is sacrificed to insurer and drug company profits. Yet, the liability is the physician’s. The cellular biology of today is 40 years ahead of the tissue physiolohy we learned in medschool. When Obamacare will be upon us, it will be a bureaucratic rubric cube 20 years behind today’s medicine’s cutting edge. So, tomorrow’s medicine may well be 60 years behind the science. How in God’s name can you expect someone who went into medicine to give, give
    give….so that patients can get, get, get…the best care possible not to eventually become suicidal under these circumstances?

    Doctors are “guilty” of nickle&dime fraud, in everyone’s eyes, until proven innocent. Physicians are seen as rich blood suckers by patients paying a $20 co-pay while unfazed by spending $120 for the baby’s sneakers (they’re so cute!). Of the ten minutes you get for a patient, five is spent explaining why “NO” to Rx a drug the patient saw in a TV ad. And you can never win because, afterall, we all know: “MD=CROOK”!!!

    When we feel that is a particular case, “the right way” is wrong, we don’t know why. We also know that a lot of our CMEs were acquired learning fraudulent or tricked data, like the use of Beta Blockers pre -op or that Lipitor os OK for patients on Verapamil. All the while we notice that the grandkids understand DNA/RNA and epigenetics better than us. Try it yourself; check-out Utube on “new” biology for kids and see how well YOU can handle it.

    Physician heal thyself….”Do no harm to yourself is not enough” because by the time you feel harmed you are already injecting Na Tiopenthal into your vein without fully realizing what you’re doing. By the time the question pops in your mind: “IS THIS ALL THERE IS?” it’s already too late.

    What MDs need to live is not more O2 or hydrocarbons or CMEs or recognition but ***TIME***:
    TIME to study molecular medicine and prove to him/herself that he/she can harness and used to heal…..that means physicians need a SABBATICAL every two years like any academic to read….
    TIME with patients to make every one of them partner so that “WE,” together can heal what ills him/her.

    Once you give an MD time and e-help to do all that, he/she will no longer be overwhelmed, going into shutdown mentally followed by physical shutdown through suicide.

    Ha! And the AMA has recommended that hospitals do spot drug checks on attendings. That’s insult on injury, further degrading physicians. Why not do “cash-check”on the AMA to see who bought it into that proposal. Did it ever do anything to help physicians heal themselves by getting on top of the healthcare challenge? No….to the AMA you’re a junkie and a crook– guilty until proven innocent…only the for-profit agencies are good guys….AMA also loves the corporate cannibals that soil medical journals with stupid ads. But that’s another story….

    • Pamela Wible MD says:

      Yes! TIME! I just got off the phone with a physician in NY. All he wants is TIME. Uninterrupted time with patients. Time to fully evaluate and treat his patients. Time to rest and relax on the weekend without fear that he will not meet his overhead this month.

  3. Pamela Wible MD says:

    From a third-year medical student:

    “As a person who has lost everything to pay for the medical bills of my premature daughter, as a woman who worked waiting tables, bartending, and as a florist, and now as a medical student- I respectfully disagree with comments [regarding rich, greedy, self-serving physicians].The rising costs of medical care didn’t come from the greed of physicians, but the greed of insurance and pharmaceutical companies. You won’t find a physician living in a $20 million dollar home, but those homes are full of pharmaceutical and insurance moguls. I’m entering my third year of medical school (only halfway done) and I currently owe $142,000 at 6.8% interest. I could get an auto loan for a better interest rate. I struggle to live on $13,000 a year while attending school and worry about how I will pay for my daughter’s after school care. I lose sleep at night wondering how I will pay back this enormous amount of debt on the salary of a resident physician ($35-40,000). This would be a great salary if I didn’t graduate with the debt equal to a mortgage. I will be at least 30 years old before I can practice on my own license. At age 30 I will finally have a “real job”. No savings. No retirement. I don’t own a home. Here’s a great article: http://www.er-doctor.com/doctor_income.html

    As I said to my hair stylist last week: “No job is more important than another. For the doctors that think their profession somehow makes them better I would like to see them grow their own food, build their homes, fix their cars and drill their oil. We are all interdependent and need each other to have a community.”

    “So please, be nice to your doctors. I don’t know any one of my classmates that are going into it for the money. We give up the better part of our youth, sacrifice a depressing amount of time away from our family and friends and often our own health to care for you and your family. Every life lost to suicide is tragic, and physicians deserve the same empathy you would award anyone else.”

  4. Margaret Perritt says:

    I am a 75 year-old retired college administrator living on the coast of Maine in a beautiful working waterfront community. We are loosing our 105 year-old Critical Access Hospital on the first of October. It happened behind closed doors and was a done deal before we knew what was happening. Strangely, the patient base learned of the impending loss of services when someone dropped the news in the vegetable aisle of the local grocery store! Since that time, a very vocal and angry community has been fighting to try to save the hospital but it looks as if that is not going to happen. We have been taken over by the big boys and they do not see us as people–just numbers. The thing that hurts most is that we see this as loss of accessible, affordable healthcare. It is not like Joe’s Shoe Store closing because no one wants their shoes…..it is our ER; our acute care beds; our ability to die at home, etc., etc., etc.
    Now we have formed a Foundation and we are looking at opening our own Acute Care Center based around a family practice with special clinics to meet the needs of the community. We are told that no young doctors will want to come to work here…that they all want to work in the big hospitals…and-get this-that doctors don’t want to work long hours any more. We can’t do this without good doctors and as I read the postings here, I am wondering if we could be creative in the way that we recruit. Suppose, for instance, that we paid off the student loans in exchange for a promise of a certain length-of-stay? I am reminded of Joel when he went to Alaska in “Northern Exposure”! Suppose we offered a sabatical leave of six months for every five years worked? What could entice fresh new doctors to come to a coastal peninsula in Maine and be involved in helping us reach our vision of an “Empowered, Engaged, Healthy Community” ?

    • Pamela Wible MD says:

      YES! Communities CAN recruit doctors on their own. The key is DISINTERMEDIATION: removing the middle man. A doctor would love to come to community and care for the people on the coast of Maine. I’m happy to help you.

  5. Pamela Wible MD says:

    Hi TC ~ More and more doctors are choosing not to be abused. You can’t be a victim and a healer at the same time. I keep repeating this because it’s true! I struggled through med school and I knew I was not the only one. I kept a diary so I could one day share my stories to help others. It is so important to share the truth of our experiences with one another. You can liberate yourself and others. Just by telling the truth. Sharing the pain.

    I hope you can come to the retreat: http://www.petgoatsandpapsmears.com/retreats.php I have them twice yearly and scholarships are available for students. It will really help you heal from the trauma of your training and be a beacon of light for others, patients and doctors. Everyone seems to be suffering The solution is so simple.

    Please share the book with your classmates and attending physicians. We CAN have ideal care for everyone. It’s not rocket science. All book proceeds go to open more ideal clinics. A win-win-win situation!

    You can call me anytime if you need help. 541-345-2437.

    🙂 Pamela

  6. Dr. HB says:

    Just read your article on consultant live on “why doctors commit suicide”. Right on the mark! We can’t just be like regular people, workaholism is considered a desirable trait in this profession and we are not allowed to fail. At the end of the day, I spend more time admiring the life my non-physician friends lead, than I do admiring my own..they seem to work less hard, enjoy life more and have the respect of their spouses and kids more than most docs I know……..I always looked upon medicine as a calling, and love dearly helping people get well, physically and emotionally, BUT AT WHAT COST?? My patients are always telling me “you should take a vacation” but God forbid I am away when THEY need me…then I get an earful from the family and referring doc. We need to redefine what it means to be a physician IN THIS DAY AND AGE….not circa 1950’s models. Thankyou for bringing forth the issues that trouble contemporary doctors, dealing with the practice of medicine in this 21st century.

    • Pamela Wible MD says:

      Yes. We must first be human. Then doctors. I led town hall meeting before opening my clinic (designed by the patients) in 2005. I collected 100 pages of testimony, adopted 90%, and opened one month later. #1 request by patients is a humanized experience with a human doctor. One woman wrote, “I want a doctor who works in a calm, relaxed space with plenty of time off.” So what’s stopping us Dr. HB?

      • Dr. HB says:

        There is a warped sense amongst physicians that , in order to be “valued ” by our patients, we have to be “needed”. So we do crazy things, like wear our pagers during off hours, never say no to that 5:15 add on, and set no limits on the number of times we respond to a patient’s incessant calls about their constipation, phlegm, insomnia and other plagues of living a fairly typical life. We need to set reasonable limits on what our patients can expect from us, in terms of our work environment, hours, availability,etc, but then honor these limits by keeping waiting times short, answering calls promptly and given them our full attention every minute we ARE with them. This is the biggest issue I have with these “concierge” style practices–it magnifies this problem even more by letting people know that now, if they can pay, we are willing to be abused even more…for what…MONEY! Unfortunately, our elderly patients, who grew up with the hierarchy of ” whatever the doctor says, I obey”, have trouble with the contemporary and more ideal doctor-patient relationship wherein we have a meaningful, thought-provoking, back and forth discussion, integrating our best medical advise with the patient’s expressed wishes and willingness to participate in the healing process .

  7. Its so bad happening with physician who care us and kill them with overdose…. we have to be strong and share things with love one to get solve the problem.

  8. TC says:

    Dr. Wible,

    I was recently introduced to your writing from the KevinMD repost of this article. It really resonated with me. It’s a harsh reality that many high strung professional go through, and physicians are no exception. I’m in the 3rd year of medical school and I’ve struggled throughout the second year to justify how much of this journey has been worth it. It felt so overwhelming at times the amount of minutiae that we were responsible for that I started to feel like my purpose became acing multiple choice questions and less about the art and humanistic side of medicine. I became very anxious and sad throughout school and have received professional support, though it will not change the fact that the nature of medical training won’t be changing anytime soon.
    Getting through my first board exam I was so glad but also discouraged at the same time when i imagine how it won’t be any different the next few years–test after test, moving here and there for rotations. It made me feel really helpless and hopeless. I started my first rotation recently, and though I’ve had some great interactions with a few nice doctors and patients, the majority of the time I’m dealing with doctors who are overworked, overwhelmed, and outright ordering lab tests left and right. Every patient became a checklist of things to get done including the enormous amount of documentation in the form of admission notes, progress notes, and discharge notes, lab tests, and prescription orders (you need to put in an order for finger-stick before the nurse will do it).
    The patients on the inpatient floors were constantly having their blood drawn so often that their arms look bruised. So many tests were ordered not just to rule things out, but to cover bases just in case the doctor was ever questioned by a superior or even worse…in case of malpractice. It just felt wrong and wasteful. Seeing how overworked the residents were made me question if there was ever a light at the end of the tunnel (when I would ever be able to practice medicine the way I’ve dreamed).
    I am so glad I picked up your book. I read it pretty much in one sitting and it was like “Chicken Soup for the medical student’s soul” for me. It alleviated a lot of cynicism and hurt I’ve been feeling so far. I laughed so hard, I learned so much, and got to read about doctor-patient interactions that felt REAL and NOT sterile or superficial. I really appreciate the honesty and love that you put into your writing in order to share your experiences with us. Today, I definitely feel a bit more courageous now, more optimistic and hopeful, and ready to laugh more (less moping and crying) especially at the ridiculous things that this journey entails.
    It’s never been easy to admit that I’ve been unsure of my choice to go into medicine. There were so many days where I would look up other degree programs thinking of the great escape, feeling like I should’ve have gone into a Master’s in therapist/counselor instead, at least they spend more time with their clients. I often felt like a minority–maybe too idealistic, and have a tendency to focus more on the humanistic aspects. Some of my colleagues seemed more hardened, focused, and driven. I felt really frustrated, and trapped.
    It really gives me great comfort now to know that one day, I can practice the way I dream of and it’s up to me. Maybe I’ll have a small Psychiatry office (minimum overhead fee, no front office staff, do own billing), see 8-10 patients a day, definitely with a relaxing fountain and beautiful sliding doors and comfortable couches. No pressure to prescribe a patient medications just to get them out the door, and more time to do talk therapy in conjunction. All of this seems feasible now even with all the student loans as long as I’m not yearning for a Porsche or 10 bedroom mansion. I guess fear really narrows the focus of what could be possible.
    Thank you for putting yourself out there. I imagine it takes a great deal of courage and love. I just wish there were more mentors like you out there, to inspire students instead of intimidate them. Thank you again, and I hope I will have the pleasure of meeting you in the near future.

    -TC

    • Pamela Wible MD says:

      Thank you so much for putting yourself out there. WE need more physicians and medical students to stand up for themselves and the truth of their experiences. Remember: You can not be a healer and a victim at the same time. <3 Pamela

  9. Bill says:

    Thank you for what you’re doing, Doctor. My niece, off to med school in two weeks, has your book with her. Make sure you take time for yourself and loved ones.

  10. D-C says:

    1st, Thank you Pamela, for what you’ve started for physicians, and for presenting this particular topic. It’s sad there are people who clearly out of ignorance, foster erroneous assumptions about doctors getting rich. Unfortunately these same people tend to demand overly-simplistic solutions to all complex issues.

    The stress imposed on Health Care Professionals is greater than most people are aware. As a society, we’ve become more contentious, opinionated, and polarized in those opinions, including Health Care and suicide. A google search of “litigation” and “stress” quickly reveals how vulnerable Physicians are, in addition to their daily stressors.

    Not being a Health Care Professional, I hope to get feedback on this topic from a different angle. The PA-C who treats me has been my primary care provider for many years (w/a lapse of a few years while litigation left nothing for healthcare). 12 years ago, she was the one who correctly assessed my symptoms were related to my lumbar.

    During an appointment a few weeks ago, I succumbed to my own physical pain & situational stress, voicing frustrations (in a manner I Don’t use), and also let my guard down, revealing – “Yes, I’ve thought about ‘it’ every morning I wake up for the past 3 – 4 years.”

    This kind, caring, Professional is someone I deeply respect and sincerely regret my lack of verbal restraint. She seems to understand my frustration wasn’t directed at her but my language was inappropriate & I never intended to put such a burden on her. There’s nothing she can do to change the situation. It’s not “Clinical Depression”. It’s strictly “situational” & social (people can’t handle uncomfortable realities, illness, financial, legal, etc), and I’m ashamed for not showing more restraint.

    My question to you as Professionals, at my next appointment in a few weeks – is it appropriate offer Amends? (I apologized but not adequately) Ask if she’d rather I made future appointments with someone else? Or just assume she doesn’t need to burden, & change the appointments out of respect for her?

    This PA-C is among the few precious souls who’ve shown patience & tolerance for my situation over the past few years, and doesn’t deserve this futile burden. I’m well aware my current physical presence reeks of “stress” & I more closely resemble an abused stray animal.

    Your thoughts would be very much appreciated. She deserves better from me. (I hope it’s appropriate for me to pose this question to you) Thank you.

    • Pamela Wible MD says:

      I think giving feedback to your health care provider can be invaluable. It is best to write a letter from a pace of compassion for yourself and your physician or PA. Let me know how it goes.

  11. D-C says:

    Thank you for your wise suggestion.

  12. CN-CH says:

    This is one of the reasons I chose not to enter the US Match for residency, and instead accepted a position in Switzerland. As a married father of two little girls, I could not see myself being anything but miserable working 80-plus hours per week for the next 3-5 years. In my Swiss residency (at a highly regarded university hospital) I work about 50 hours per week, and actually have some time to spend with my wife and daughters.
    It is not perfect here, but it is a heck of a lot better than what my friends have been reporting from residency (and practice) back in the States. Thank you for talking about this, Dr. Wible. It makes a difference.

    • Pamela Wible MD says:

      Good to know that the grass is greener somewhere. The first step to changing things is claiming the problem.

    • SteveofCaley says:

      Good for you!
      I’m a little older, and have finished my residency, got the Certification, and all that. I’m worried about the direction of US medical training, so I spoke today to a program administrator in a neighboring country (let’s call it Canada for anonymity’s sake.) I’d love to finish my career up training and bulletproofing the new doctors coming on.
      UGH!
      I haven’t spoken the Medical Administrator/Program Director language for a long time. It’s similar to Parseltongue but not as comforting and reassuring, for those who don’t speak it.
      “USSSSSSSSSSSSSS trainees get three years of internal medicine training. In Canada it is a four year program. Do you want me to put you in touch with our residency director to complete your training?”
      EWW!
      I sure hope that the Suisse are more civil than that. If I could have sworn at the fellow in gutter French, I sure would have enjoyed it.

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