Physician suicide and medicine’s culture of betrayal

Kevin Pho: Hi, and welcome to the show where we share the stories of the many who intersect with our healthcare system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Pamela Wible. She is a family physician, and she’s the author of the free ebook Physician Betrayal: How Our Heroes Become Villains. Pamela, welcome to the show.

Pamela Wible: Thank you so much for having me.

Kevin Pho: So we’ll get into your book and excerpt in a little bit, but first off, can you share your story and journey to where you are today?

Pamela Wible: I’m a family physician. Both my parents are physicians. They warned me not to pursue medicine. And their warnings were economic predictions that have come to pass—loss of physician autonomy, assembly-line medicine, seven-minute visits. What they never warned me about was the emotional impact of the career. So all economic, not emotional. Never once did they talk about their own anxiety, depression, suicidal thoughts. And so I was left in a very isolated state feeling like I was the oddball, the only one having mental health problems, and come to realize we have a real physician suicide crisis that I stumbled upon by personal experience.

Kevin Pho: Of course, you need no introduction in terms of being at the forefront of bringing awareness to physician mental health and physician suicide. Tell me how you first got interested in this issue. And when did you realize that it is such a big issue?

Pamela Wible: We had three physicians that died by suicide in my town, in Eugene, Oregon, in just over a year. And that was in 2012. I was suicidal in 2004, and at the time, I thought I was literally the only suicidal physician that ever walked on this planet.

I’m currently writing my memoir and as I examine my repressed memories from childhood, I’ve realized, “Oh, yes, my mother is a suicidal psychiatrist.” I think I hid that from myself. A lot of us hide our own personal pain because it’s just too much. When I’ve been asked, “Why do you run a suicide helpline?” I’ve said, “Because I survived suicide as a physician, so I want to help my peers.” That’s a superficial answer. The truth is I was an embryo inside of a suicidal psychiatrist so I feel I’ve been running a suicide helpline since I was born or conceived, quite honestly. So I guess that would be the true answer.

Kevin Pho: So you mentioned you run a suicide helpline for healthcare professionals. Please talk more about that.

Pamela Wible: I never intended to run a suicide helpline, yet people were utilizing me as a suicide helpline. Since 2012, when I became vocal after the deaths in my town, people have been wanting to tell me the suicide stories of their children in residency, in medical schools. Suicidal doctors and med students are contacting me—even internationally from Germany and Poland. Especially amid the pandemic, I had a greater influx of calls. I do have a lot of passion for this, and people seem to be thanking me for helping them stay alive. At one point the most common first line in an email from those who sought my help was “I would have been one of your statistics, but you answered the phone, I read your article, I saw you on KevinMD or read your book.” If that’s the response, I feel compelled to keep going.

Kevin Pho: Now, when you talk to these suicidal healthcare professionals, in general, what are some of the root causes that brings them to the brink of suicide?

Pamela Wible: We have a lot of unacknowledged occupationally induced mental health issues, including obvious trauma. If you’re a trauma surgeon, I mean, it’s built into the name of your specialty. You’re traumatized by watching people on the edge of life and death and telling parents their teenagers are dead. So I think we have to realize that even on the best day as an obstetrician, you could have a stillborn after a happy birth and then a maternal death the next day. And so there’s no specialty that’s not traumatized. And then to not be able to get mental health help because we’re worried about career repercussions. We also have internal dialogue—we feel like we’re supposed to help others and not ask for help. We have a very dysfunctional culture of emotional and spiritual disconnection from ourselves in medicine which causes these wounds.

Kevin Pho: You’ve been bringing awareness to physician suicide and physician mental health for years now. And of course, we’ve been talking about clinician burnout, clinician mental health on KevinMD for years now. Now, talking now in 2021, have we moved the needle in the last five to 10 years after all the advocacy work that you’ve done and all the KevinMD articles that you’ve written and all the speaking appearances that we’ve done? Have we moved the needle? And if so, how much has that needle moved?

Pamela Wible: Yeah, absolutely. At the beginning I could not even get the local newspaper or TV to report on the doctor suicides in my town. And now, at least occasionally, they’re hitting the headlines and they’re actually printing suicide in the articles. Hospitals are reaching out to me in the aftermath of suicides and having me lead postvention, immediately, within 24 to 48 hours of a death in their hospitals so that physicians get the help they need. The real problem with suicide is the secrecy. Secrecy is the genesis of more suicides when it’s not handled up front because it leaves the other passively suicidal co-residents and hospital employees feeling like, “Wow, this guy died in isolation. We won’t even talk about it. I can’t talk about my pain.” And so suicide becomes a more visible way to end the pain when you can’t find any other outlet. Nobody really wants to die by suicide. They want to end their pain. And that happens when we connect with each other and actually speak honestly about our experiences.

Speaking of moving the needle–an Emmy-winning filmmaker contact me back in 2014 and completed an award-winning film on doctor suicide prevention that’s been shown at more than 300 medical institutions to start the long-overdue dialogue on physician mental health (see film trailer below).

Kevin Pho: So when you talk about the secrecy surrounding physician suicide, what exactly do you mean?

Pamela Wible: The unwillingness to say the word out loud. The way that we will often miscode death certificates as accidents when we know the guy was in the middle of divorce or a malpractice case and he drove off a bridge. We’re in a unique profession in which we can complete the death certificates on our peers.

Unlike veterinarians or construction workers, we are in a position to hide these suicides. We are literally covering up these death out of our own denial. Even I was avoiding the truth about suicidal thoughts within my nuclear family. It’s easy to be in denial because it’s painful, but we’ve got to talk about it.

And, yes, we’ve moved the needle. I’m doing keynotes for surgeons who want to address suicide now. Just this last Sunday, I led a free surgeon support group, and to have these older male surgeons breaking down and crying with one another, I mean, that’s moving the needle. I’ve never seen that before. And it’s great. We need to cry. We need to release the pain. Like I said before, I feel like we all need to do a personal emotional I&D (incision & drainage) on ourselves. Otherwise, we are literally walking around in emotional sepsis. When surgery interns ask, “Why is there bullying in the OR? Why are these surgeons acting this way?” I try to use surgical terms, “Well, it’s just emotional exudate. They can’t help it.” Hurt people hurt people. You can’t contain an abscess that large, you’ve got to slice it open and let it out, at least in a journal in your home, or talk to a friend, or go to a therapist, or call me and talk to me for free.

We cannot afford to lose one more physician to suicide. The wall of honor is particularly moving at the end of the documentary:

Kevin Pho: So when you talk to these healthcare professionals on your hotline, what have they tried in the past to help address some of the behavioral health issues and some of the depression and burnout and anxiety that they’re facing? What have they done prior to calling you on the hotline?

Pamela Wible: Well, most of them have done nothing, and that’s the problem. And then sometimes when I hear from people, they’re on the brink of disaster. I’ve heard from a physician in the ICU after a suicide attempt. So a lot of times, just like our patients who wait till they have a heart attack to make their dietary change, physicians wait till they’ve got a major disaster looming. Most docs just try to suck it up, pretend like it’s not happening until it completely overtakes them. One cool thing is that sometimes people will write me these tomes of emails, and they’ll conclude at the end, “I feel so much better for sharing this for the first time in written form. Don’t even worry about calling me back. Just thank you for reading this.” So that’s kind of cool, just writing it down allows you to feel like there’s somebody on the other end that you can trust, that’s not going to report you to a medical board. And it’s especially great to get people in the same specialty together. That’s why I do these specialty-specific peer-to-peer support groups. I’m not a surgeon. I don’t know what it’s like. They do. These people are replaying every accident or bad outcome they’ve ever had in a 30 year career, like as an ongoing videotape in their mind. They can’t sleep at night. I don’t have this problem. Not in outpatient primary care. I’m not replaying cases in my mind.

Kevin Pho: So when you are bringing awareness to physician suicide, have you received any pushback? And share some of the challenges that you’ve faced and overcome in bringing more awareness to physician suicide.

Pamela Wible: Well, the pushback early on was from the widows of the physicians in my town. I never outed the victims by name, I just wrote an op-ed about our local crisis. There’s never a convenient time to talk about suicide because there will have been one yesterday or two days ago and somebody’s going to be grieving and they’re going to lash out at the first person they can. That’s usually me. I’m the messenger. And that’s okay. I don’t mind.

I think what’s shocked me is the amount of vitriol that’s come from some ego-bruised female psychiatrists which is interesting historically with my psychiatrist mom. I’m in a bit of a pattern with angry female psychiatrists. But it’s a small subset. I’ve been told essentially “Stay in your lane. This is our area.” I run a free suicide helpline. I happen to spend thousands of hours listening to physicians crying on the phone. I don’t think this is a specialty specific job. I feel we all need to help each other.

What I found really interesting is during this last Sunday’s suicide support for the surgeons, there’s one guy in there who just literally was inpatient psych several weeks ago, and he’s not sure he can make it day by day. I’ve hooked them up and he keeps calling me and the others. And so, he’s still alive. He’s a cool guy, head of a department, head of a residency. You know what I mean? This guy is awesome and he’s never shared this information with anyone. But he, at the end of the call, said that spending the two hours with us was more helpful than any therapist he’s seen, anything they did in inpatient psych, any help that he’s gotten yet. And I feel like that’s because this is targeted physician-specific help. It’s not like blasting people with chemotherapy for all cancers. Targeted to a very specific subset of people, a very specific psychology, and they need to be handled in a specific and a non-generic way. And that’s not what happens when you get thrown into inpatient psych or treated, unfortunately, by many therapists. So, yeah, I’ve had pushback, but I have thick skin. I can handle it. So I just keep moving.

Kevin Pho: What are some examples of some of the criticisms that you face?

Pamela Wible: Well, I always know when I’m getting lambasted, usually in private sites. They don’t do it to my face or there’s never live conversations. You know how vitriolic it can get on social media. I’ll get these Facebook private messages, “How are you holding up? Are you okay?” And usually when I get those, I know I’m being skewered in a private group. And it’s often before I do a speaking event. They’ve actually contacted the places where I have speaking events and tried to get me fired while I’m there. They’ve boycotted the events. They’re a very angry, small subset of mostly female psychiatrists.

So this person that leaked this to me, I was like, “Well, what are they saying?” He’s like, “I really think you should respond.” “How can I respond? They’re doing it in a private group.” He goes, “Well…” I said, “You know what? It’s probably mostly female.” And he’s like, “Oh yeah, I looked at it. 75% female.” And I was like, “Yeah, because women can beat the crap out of each other viciously, verbally in a way that men just can’t.” And so he’d send to me screenshots and he sent me a whole spreadsheet of the things they were saying. And one of the things was like, “Oh, I can’t believe that they’re calling what Dr. Wible does research. I mean, that’s like saying my two year old wandering around my house collecting bugs and leaves is doing research.” And I’m like, “That is research for a two year old.” And it’s so funny. They’ll say things like, “I can’t believe she’s making money off of human suffering.”

So I literally went up on stage during my full disclosure slide and started reading all the vitriol that they left for me online and answering it in front of hundreds of psychiatrists. I have no conflict of interest. I’m not hired by Merck. I don’t have anything to disclose on my full disclosure slide. So I fully disclosed that there’s a subset of physicians who don’t like me. And I just started reading everything they had to say and answering it on stage, and people were laughing so much, I ended up doing standup comedy in NYC after this. So I have to thank these people for bringing it up because I do think controversy and talking about these conflicted thoughts really helps us grow personally, and I think tragedy and comedy are connected. And a lot of times when I speak about suicide, I mean, I’m getting standing ovations. I never expected it. But people really have a need to hear the truth. One of the things that I thought was funny that they said is like, “She’s making money off of human suffering.” When I said that I was like, “Oh, wow. Wait, don’t all doctors make money from human suffering? Raise your hand if you’ve never made any money from human suffering. Right.” And I’m not charging any individual physician for helping them. Yes, I charge for keynotes, but that’s like 10 years of amassed research on physician suicide that I’m sharing and graphs and charts, and that took a lot of time. But, yeah, I’ve never charged an individual physician who’s suicidal in 10 years for help. But it’s fascinating, the response that I get from a small subset of people.

Kevin Pho: You’re also the author of a recent book, Physician Betrayal: How Our Heroes Become Villains. There’s an excerpt on that on KevinMD titled Medicine’s Culture of Betrayal. Tell us more about your book.

Pamela Wible: I was in the middle of writing a memoir and then, I don’t usually get writer’s block, I had writer’s resistance during a betrayal scene with my dad at age 13, mostly because he’s a workaholic physician and I never see him. And so I was trying to piece that together. And at the same time I have this little coaching group of doctors and I was like, “Oh, why don’t we do a 30-day book challenge? Let’s see who can write a short e-book in 30 days?” Because I’d like physicians to start expressing themselves and sharing their personal stories. About 10 of them took me up on it and ended up authors at the end of the month, which is awesome. But I like to do it along with them. So I wanted to show them how easy it is to write a book in a month. So I did this 32-page e-book in one month, which was a very painful exercise, but it helped unearth material that allowed me to continue on my memoir. So what I have on KevinMD is chapter four from the book. I feel the core issue we’re all dealing with is a sense of betrayal in our profession, because we come in as these idealized, young, do-gooders and then we’re faced with unethical scenes that we’re in and things that we witness in which we literally have to betray our own ethics to continue our attachment with this career.

Here’s a definition I’d bet people can relate to right now during the pandemic, “Institutional betrayal trauma occurs when the trusted medical institution that teaches trainees how to be healers fails to protect them and can so deeply contradict what is expected that medical professionals will end up blocking their trauma in order to maintain attachment with the profession.” I feel we’re all in various states of institutional betrayal trauma, and the sooner we talk about it, the sooner we can recoup our profession and become the healers that we had intended to be. Our profession is not going to right itself on its own. We need a deep soul search individually and professionally as a group. My chapter on KevinMD might have lost some people, but I do think the book is pretty good—it’s a deep dive into our own psychology as physicians and healers.

Kevin Pho: So give us an example story or a case study of how an institution would betray a physician.

Pamela Wible: Well, I think it starts in medical school. For me, it started in the first year of medical school when they had us do dog labs. And thankfully, that’s not how happening anymore as of 2008, I believe. But literally just to see on my schedule that I was going to go into this physiology lab and murder a dog that was somebody’s prior pet for no other reason than to study the EKG flatlining and look for heartworms, I was like, “This is ridiculous. This is not anything that’s going to ever help me with a human patient and could be learned in a different way if we’re just trying to study EKGs.” But the physiology instructor told me straight away that, “This isn’t an experiment. This is an experience, and there’s no alternative.” You know what that is? It’s an experience in methodical dehumanization, which is what happens to us in this profession which is almost run like a cult, which is why it’s so hard to get away and so hard to retain yourself when you’re in it. And it happens just slowly over time, like this betrayal grooming. And it starts with your own choice to act against your values, like death of the soul by a million paper cuts from day one. And then people find themselves in a state of detachment, loss of joy. I mean, this surgeon who was suicidal, he gave his life to this profession. He’s an esteemed head of a department and he feels like, “What was this all for?” He lost his whole life. He was not really joyful in the profession. He just did what he was supposed to do as a good guy. I think we have to stop and pause and really reevaluate, “Am I in a career cul-de-sac? Do I have joy? Am I getting to live my life?” Because we, as healers, should get to live our lives and enjoy ourselves and have real joy personally and professionally. And if you’re not feeling that, don’t wait until you’re in ICU after a suicide attempt to reach out. Start talking about it now. Pretty much I bet all your peers feel the same way.

Kevin Pho: We’re talking to Pamela Wible. She’s a family physician. She wrote the KevinMD article Medicine’s Culture of Betrayal, and she’s the author of the book Physician Betrayal: How Our Heroes Become Villains. Pamela, what’s next for you in terms of moving the needle when it comes to physician behavioral health and physician suicide? How are you going to continue to move that needle?

Pamela Wible: Well, I think finishing my memoir is next because it’s been more helpful for me than any therapy I’ve had, and I’ve had 20 years of therapy. I think when you really sit down and fearlessly, go back to the worst scenes in your life and marinate in them enough to write dialogue, and then with the mind of a healer, with the wisdom of somebody who understands the DSM, who obviously didn’t have a grasp at it at age nine, when you can apply your adult knowledge to scenes in your life that never made sense to you, you finally have enough understanding of why you are where you are in the world and how to use your gifts to heal yourself and others. I think a lot of healers are very other focused, like, “Let’s heal other people.” And what I’ve learned from training hundreds of doctors to run their own practices is really their ideal patient is themselves. It’s a mini-me. We’re out to heal ourselves by focusing on others, but if we pause for a minute and really, truly heal ourselves by being introspective fearlessly, which is hard to go back into your painful moments of betrayal in your childhood and beyond, you will have such a depth of understanding of who you are that you’ll be able to give from a place of true insight, wisdom, and resourcefulness versus algorithms, cookbook medicine–and that’s failed us in psychiatry.

Kevin Pho: And my final question, what’s your take-home message that you want to leave with the KevinMD audience?

Pamela Wible: Similar to me, clinicians out there, you have entered medicine without informed consent. I am a real fan of informed consent. People must understand what the impact is of any choice, of any medication, of any injection, of any career choice, right? And I’m sorry. I just want to say I’m sorry that you, like myself, did not understand the emotional impact of this career, but now we are at a time in human history when it’s okay to say suicide out loud. It’s okay to say that you have PTSD as a trauma surgeon. It’s built into the name of your specialty. It shouldn’t be a shock. And so please ask for help. I have free confidential 10 years of resources, including so many KevinMD articles I could give to you if you just reach out for help. You don’t have to Google all night long, searching for things. Contact me and I can hook you up with recordings, with peer-to-peer support, with articles. So just don’t do this alone. We talk a lot about teamwork in medicine. You should not go into this profession with a lone-wolf attitude. You need a team. Every one of us needs a team of healers around us. You need an emotional support team to make it through this profession with your heart and soul intact. You deserve it, and it’s your birthright to be happy.

Kevin Pho: Pamela, thank you so much for sharing your time and insight, and thanks again for being on the show.

Pamela Wible: Thank you.

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