At the recent TEDMED Conference in Palm Springs, CA, Dr. Pamela Wible gave the second talk of the conference, one that electrified the audience.
In the past, she has spoken on physician suicide widely, dramatically and effectively. At TEDMED, her talk got a standing ovation from a diverse audience of scientists, techies, industry types, financial types, and some doctors too.
And every person I spoke to afterwards, with varying degrees of surprise, asked me 'whether it was true'? And 'why were we just now hearing about this? And why are we responding with the words 'open secret'? Seriously, two medical school classes-worth of doctors, students and trainees are killing themselves every year and this is not top billing at every medical conference in the land?! (Seriously, I can attest to the fact that the Dean for Graduate Medical Education at one of the largest residency training programs in the nation confessed to not knowing this. Today. How is this even possible? How does a system that does so much to train doctors and care for their welfare, not have organized its entire purpose for existence around this fact?)
And I found myself at once agreeing with them, that yes, this was indeed true and awful, and as is true of all the violence in the world, it's only when we put the numbers together that we see a pattern, understand the scale and size of the tragedy. And yes, we have known about this, and yes, in our own ways we have grieved and responded and improved conditions to prevent such failures of compassion within the very profession built upon healing and empathy. But we need to do more.
And as I spoke all these words, and thought all these thoughts, the feelings I felt were shudders of my own difficult medical education journey and training. The one that I have put behind me, slammed a door tightly shut against, vowing never to return to that place again. I jokingly say, "there is not enough money in this world that will make me go through residency training again". The shine of moneyed superficiality lining the darkness that lurks beneath that statement.
And the truth is, historically the medical profession has been one which prides itself in being difficult to handle. Our very specialness comes from this notion of having made it through a trial, we are branded, anointed, gladiators wearing our wounds with pride. Sneering at those with less than savage hearts, we create a hierarchy where the cult of personality rules and the 'giants' roam the halls. These doctors in their long white coats dispensing wisdom from on high dropping knowledge on the incoming interns waiting below with cupped hands, is part of our folklore.
And so it was in a time when medical practice was beginning to turn into a science, and knowledge was carried around inside our heads as much as in our books, and so the legend of the 'doctor as deity' was still a necessary tool of the trade in Western medicine. Patients come to doctors for many things, a diagnosis, a treatment, a consultation, an opinion. But also, they come for that singular moment when they look into the eyes of this other human being, put their entire trust in their abilities, and hand over their most precious possession into the doctor's keeping. Trust. And to gain the honor of being able to wield such power was rightly guarded and protected, lest it be misused.
And upon these rituals of early and mid-twentieth century medical training, came the Molotov Cocktail of reality in the form of Big Insurance, Big Pharma, while the democratization of knowledge led to an explosion of medical school graduates, all created upon the blue prints laid out by Abraham Flexner, Johns Hopkins and the big academic centers of the time. Two years of pre-clinical lectures and labs, followed by two years of rotating through various specialties gaining a wider understanding of the scope of medical practice. Built upon this was ritual and rite, the passage from medical student to doctor one of hallowed significance and honor. Remember, this was also around the time we were trying to figure out how DNA worked. There was no 3D rendering of x-radiation in the form of CT-scans, no ultrasonic sound waves making images on screens, and definitely no way to probe the folds that lay beneath the cranium, short of cracking it open with a bone saw.
Residency training programs in those days weren't as regulated, or even regulated at all, medical education as a concept didn't exist, beyond what was printed in hefty tomes and scratched out on chalk boards. Urine tests were run using strips at the bedside, and diagnosis was more an art form and less the science it was yet to become.
And somewhere, around the time that the first televised war was being watched around the world, we saw trauma for the first time. Humans for the first time saw other humans suffer in great numbers, saw themselves in the other, in more ways than one, and as the barriers of distance broke down, closer to home they began breaking down the barriers of gender and race.
That was also the first time doctors were openly speaking of private pain. Samuel Shem wrote "House of God", a raw, unfiltered look at how medical training and practice were changing under the weight of all that was now being asked of it. The medical establishment, generally created and maintained by the privileged few, remained unmoved. They had been through this same training and expected their graduates to have the steel balls to do the same.
But they hadn't. They had never been through this kind of training. Emergency Rooms overflowing with the homeless, derelict and drug addicted, societies ravages coming to roost on the steps of academic training centers, were placing trainees in positions of greater and repeated traumatization. The pace become precariously difficult to maintain, trainees learned to keep a scalpel, a syringe full of Haldol, IV tubing in their pockets. This was war and these were the things they carried.
And as these trainees graduated, a collective amnesia took hold. The war ended for the graduates while it only just began for the interns. Wisdom, which is created with experience and reflection, never got a chance to form, but instead a sort of manual was passed down in code. G.O.M.E.R. became the acronym for a difficult patient, gallows humor appropriately employed to convey the sense of impending doom.
And what of these damaged veterans of a war they never expected or chose? Why they were scattered out into the world, landing on fertile or barren land, blossoming or shriveling up, quietly and in isolation. Doctors began to compensate with the trappings of status and wealth, replacing the fulfillment they should have received from the medical profession and their place in it, with a fitting proxy. Doctoring went from being a profession and a calling, to being a job, a money-maker, a place where a smart (usually) man could make a fast buck and retire early. Litigation, malpractice and regulation followed. The party was over. Like teenagers throwing a rager when their parents were out, they never thought of the clean up the next morning. Or being grounded for life.
And the rest of us got grounded with them. Infrastructures were created to ensure public safety, the shield of malpractice insurance, the sword of defensive medicine, the heavy armor of CMS and the shackles of governing and licensing bodies, weighed down the profession, paralyzing and neutralizing a once great profession, the nobility of medicine only allowed to exist in small puffs of ephemeral smoke. Burnout.
Now let's talk about burnout for a second. This is a word that is soon going to lose all semblance of meaning, because it is the new 'word du jour'. Physician Wellness and Burnout are the new glues and bandages being applied to the rusty old armor, just to keep it from falling completely apart.
Burn Out. This implies, that before burning 'out' there is a steady state of burning that is reached. The implication being that as long as you don't completely 'burn out' but instead continue to slowly smolder instead, this somehow is a victory. That if only we could practice more empathy, get better at interpersonal 'stuff', do better, work harder, train more, that there lies a promised land up ahead.
And we do this. When we are young, we are robust and imagining a better future, we then aim ourselves at it, and take off at a powerful sprint. Only we must push this monster armor, this immovable carapace that barely even looks like armor, towards this glowing future that is promised us with technology, biologicals, 3D printing, apps and software that are only limited in their potential to do good by the extent of our ability to imagine them. The rapid cycling of innovation means that the landscape is shifting constantly. And the best and brightest minds in medicine, the most nimble and young and motivated minds, are unable to participate in any of it. At a conference like TEDMED, where the brightest minds are usually the under 40 set, the medical profession was conspicuous in its absence, both in numbers and voice.
Instead they must wrangle with EMR, regulations and red tape that exists more for the benefit of the machine, this system that has now spawned its own artificial intelligence and is plotting to imprison us, enslave us, use up our magic, and spit us out when its done. It hides behind patient safety, QI metrics, MOC boards, keeping us busy with jumping through hoops, too breathless to do anything more than hang on. Too burned out to care. Needless to say, our patients suffer alongside us.
And so this is Burn Out. And the suicides...those are the embers, the ones that choose to fling themselves off the crackling log, instead of waiting to be consumed.
Too soon this word will be stripped of all meaning, endocytosed into the carapace. All manner of bandages and salves applied, retreats, annual wellness days, reflection and self-care, but the problem never acknowledged.
Except, by those dying off at a rate of 2-3 a day. Only throwing himself off a building must have made any sense to the doctor who did so last year at our institution, because as others mentioned, he was young, bright, well-loved, well-adjusted. A good doctor on the cusp of realizing the goals he had worked so hard for. But he chose instead to take himself out, to call attention, to make the hum louder instead of pretend it doesn't exist. What makes completely well-adjusted, rational, highly educated human-beings decide after two decades of sacrificing their sleep, their personal comfort, their resources, their personal lives, and that of those they love, for this goal of helping, of making a difference. What makes that person decide it is not worth it. That's the question here. It's got to be something big. It has to be. The holes they leave are not person-sized or shaped. They are gaping holes that open up questions of meaning, and humanity, of purpose and redemption, of sacrifice and honor. And no amount of bandages will do.
And as children of abuse, for let's not pull any punches anymore, because really, what would be the point, the cycle continues through us. We grew up, internalized and normalized a level of abuse, which we then, systemically and insidiously, transmit to the next, then to the next, then onwards. We waste time and energy trying to heal an entire healthcare system, when the answer lies closer to home. How do you fix a healthcare system with broken doctors? You don't. You keep passively perpetuating this just-off-into-the-middle-distance idea of something that works. Something that makes sense. Because all the sacrifices you made need to amount to something. Because this means so much, it means everything.
At first my tendency towards narrative and art seemed like a purely self-serving reaction to my own burnout. My masters in medical education an attempt to grasp at some sort of meaningful frame to put it all in. But the more I continue along this path, the more it becomes clear to me, that engaging through narrative medicine is instead a kind of fortification. Of being aware of this therapeutic self as a self-created enterprise, made up of parts of the world, the past, the future and bringing it to bear in the present. In a narrative, this would be the middle. The present, if you think about it, is always the middle. And that is where things can turn, that is where it is the most vital job of the hero/ heroine to clarify their purpose, to double down on what they know to be the right thing to do, to sound the clarion call, to clear a path to safety, to create an alliance around a common purpose.
For that is the job of our present generation of teachers and mentors in medicine. To clear the way, to keep them safe, to put a stop to the cycle of violence, to provide safe haven, shelter, reprieve, protection and safe passage out into the world. For that is when the real work begins. When our trainees of the present go out into the world, engage with it, and do so in this new connected era, where they are no longer solitary David to the Goliath, but instead legions bent to rid the world once and for all of the need for monsters.
When only biblical metaphors will do, you know there's work to be done.
So go out and do it. Make your own path through, dare to bring your entire self to bear upon this, for that is the only thing that makes sense anymore at a time when even the doctors are dying.
In the past, she has spoken on physician suicide widely, dramatically and effectively. At TEDMED, her talk got a standing ovation from a diverse audience of scientists, techies, industry types, financial types, and some doctors too.
And every person I spoke to afterwards, with varying degrees of surprise, asked me 'whether it was true'? And 'why were we just now hearing about this? And why are we responding with the words 'open secret'? Seriously, two medical school classes-worth of doctors, students and trainees are killing themselves every year and this is not top billing at every medical conference in the land?! (Seriously, I can attest to the fact that the Dean for Graduate Medical Education at one of the largest residency training programs in the nation confessed to not knowing this. Today. How is this even possible? How does a system that does so much to train doctors and care for their welfare, not have organized its entire purpose for existence around this fact?)
And I found myself at once agreeing with them, that yes, this was indeed true and awful, and as is true of all the violence in the world, it's only when we put the numbers together that we see a pattern, understand the scale and size of the tragedy. And yes, we have known about this, and yes, in our own ways we have grieved and responded and improved conditions to prevent such failures of compassion within the very profession built upon healing and empathy. But we need to do more.
And as I spoke all these words, and thought all these thoughts, the feelings I felt were shudders of my own difficult medical education journey and training. The one that I have put behind me, slammed a door tightly shut against, vowing never to return to that place again. I jokingly say, "there is not enough money in this world that will make me go through residency training again". The shine of moneyed superficiality lining the darkness that lurks beneath that statement.
And the truth is, historically the medical profession has been one which prides itself in being difficult to handle. Our very specialness comes from this notion of having made it through a trial, we are branded, anointed, gladiators wearing our wounds with pride. Sneering at those with less than savage hearts, we create a hierarchy where the cult of personality rules and the 'giants' roam the halls. These doctors in their long white coats dispensing wisdom from on high dropping knowledge on the incoming interns waiting below with cupped hands, is part of our folklore.
And so it was in a time when medical practice was beginning to turn into a science, and knowledge was carried around inside our heads as much as in our books, and so the legend of the 'doctor as deity' was still a necessary tool of the trade in Western medicine. Patients come to doctors for many things, a diagnosis, a treatment, a consultation, an opinion. But also, they come for that singular moment when they look into the eyes of this other human being, put their entire trust in their abilities, and hand over their most precious possession into the doctor's keeping. Trust. And to gain the honor of being able to wield such power was rightly guarded and protected, lest it be misused.
And upon these rituals of early and mid-twentieth century medical training, came the Molotov Cocktail of reality in the form of Big Insurance, Big Pharma, while the democratization of knowledge led to an explosion of medical school graduates, all created upon the blue prints laid out by Abraham Flexner, Johns Hopkins and the big academic centers of the time. Two years of pre-clinical lectures and labs, followed by two years of rotating through various specialties gaining a wider understanding of the scope of medical practice. Built upon this was ritual and rite, the passage from medical student to doctor one of hallowed significance and honor. Remember, this was also around the time we were trying to figure out how DNA worked. There was no 3D rendering of x-radiation in the form of CT-scans, no ultrasonic sound waves making images on screens, and definitely no way to probe the folds that lay beneath the cranium, short of cracking it open with a bone saw.
Residency training programs in those days weren't as regulated, or even regulated at all, medical education as a concept didn't exist, beyond what was printed in hefty tomes and scratched out on chalk boards. Urine tests were run using strips at the bedside, and diagnosis was more an art form and less the science it was yet to become.
And somewhere, around the time that the first televised war was being watched around the world, we saw trauma for the first time. Humans for the first time saw other humans suffer in great numbers, saw themselves in the other, in more ways than one, and as the barriers of distance broke down, closer to home they began breaking down the barriers of gender and race.
That was also the first time doctors were openly speaking of private pain. Samuel Shem wrote "House of God", a raw, unfiltered look at how medical training and practice were changing under the weight of all that was now being asked of it. The medical establishment, generally created and maintained by the privileged few, remained unmoved. They had been through this same training and expected their graduates to have the steel balls to do the same.
But they hadn't. They had never been through this kind of training. Emergency Rooms overflowing with the homeless, derelict and drug addicted, societies ravages coming to roost on the steps of academic training centers, were placing trainees in positions of greater and repeated traumatization. The pace become precariously difficult to maintain, trainees learned to keep a scalpel, a syringe full of Haldol, IV tubing in their pockets. This was war and these were the things they carried.
And as these trainees graduated, a collective amnesia took hold. The war ended for the graduates while it only just began for the interns. Wisdom, which is created with experience and reflection, never got a chance to form, but instead a sort of manual was passed down in code. G.O.M.E.R. became the acronym for a difficult patient, gallows humor appropriately employed to convey the sense of impending doom.
And what of these damaged veterans of a war they never expected or chose? Why they were scattered out into the world, landing on fertile or barren land, blossoming or shriveling up, quietly and in isolation. Doctors began to compensate with the trappings of status and wealth, replacing the fulfillment they should have received from the medical profession and their place in it, with a fitting proxy. Doctoring went from being a profession and a calling, to being a job, a money-maker, a place where a smart (usually) man could make a fast buck and retire early. Litigation, malpractice and regulation followed. The party was over. Like teenagers throwing a rager when their parents were out, they never thought of the clean up the next morning. Or being grounded for life.
And the rest of us got grounded with them. Infrastructures were created to ensure public safety, the shield of malpractice insurance, the sword of defensive medicine, the heavy armor of CMS and the shackles of governing and licensing bodies, weighed down the profession, paralyzing and neutralizing a once great profession, the nobility of medicine only allowed to exist in small puffs of ephemeral smoke. Burnout.
Now let's talk about burnout for a second. This is a word that is soon going to lose all semblance of meaning, because it is the new 'word du jour'. Physician Wellness and Burnout are the new glues and bandages being applied to the rusty old armor, just to keep it from falling completely apart.
Burn Out. This implies, that before burning 'out' there is a steady state of burning that is reached. The implication being that as long as you don't completely 'burn out' but instead continue to slowly smolder instead, this somehow is a victory. That if only we could practice more empathy, get better at interpersonal 'stuff', do better, work harder, train more, that there lies a promised land up ahead.
And we do this. When we are young, we are robust and imagining a better future, we then aim ourselves at it, and take off at a powerful sprint. Only we must push this monster armor, this immovable carapace that barely even looks like armor, towards this glowing future that is promised us with technology, biologicals, 3D printing, apps and software that are only limited in their potential to do good by the extent of our ability to imagine them. The rapid cycling of innovation means that the landscape is shifting constantly. And the best and brightest minds in medicine, the most nimble and young and motivated minds, are unable to participate in any of it. At a conference like TEDMED, where the brightest minds are usually the under 40 set, the medical profession was conspicuous in its absence, both in numbers and voice.
Instead they must wrangle with EMR, regulations and red tape that exists more for the benefit of the machine, this system that has now spawned its own artificial intelligence and is plotting to imprison us, enslave us, use up our magic, and spit us out when its done. It hides behind patient safety, QI metrics, MOC boards, keeping us busy with jumping through hoops, too breathless to do anything more than hang on. Too burned out to care. Needless to say, our patients suffer alongside us.
And so this is Burn Out. And the suicides...those are the embers, the ones that choose to fling themselves off the crackling log, instead of waiting to be consumed.
Too soon this word will be stripped of all meaning, endocytosed into the carapace. All manner of bandages and salves applied, retreats, annual wellness days, reflection and self-care, but the problem never acknowledged.
Except, by those dying off at a rate of 2-3 a day. Only throwing himself off a building must have made any sense to the doctor who did so last year at our institution, because as others mentioned, he was young, bright, well-loved, well-adjusted. A good doctor on the cusp of realizing the goals he had worked so hard for. But he chose instead to take himself out, to call attention, to make the hum louder instead of pretend it doesn't exist. What makes completely well-adjusted, rational, highly educated human-beings decide after two decades of sacrificing their sleep, their personal comfort, their resources, their personal lives, and that of those they love, for this goal of helping, of making a difference. What makes that person decide it is not worth it. That's the question here. It's got to be something big. It has to be. The holes they leave are not person-sized or shaped. They are gaping holes that open up questions of meaning, and humanity, of purpose and redemption, of sacrifice and honor. And no amount of bandages will do.
And as children of abuse, for let's not pull any punches anymore, because really, what would be the point, the cycle continues through us. We grew up, internalized and normalized a level of abuse, which we then, systemically and insidiously, transmit to the next, then to the next, then onwards. We waste time and energy trying to heal an entire healthcare system, when the answer lies closer to home. How do you fix a healthcare system with broken doctors? You don't. You keep passively perpetuating this just-off-into-the-middle-distance idea of something that works. Something that makes sense. Because all the sacrifices you made need to amount to something. Because this means so much, it means everything.
At first my tendency towards narrative and art seemed like a purely self-serving reaction to my own burnout. My masters in medical education an attempt to grasp at some sort of meaningful frame to put it all in. But the more I continue along this path, the more it becomes clear to me, that engaging through narrative medicine is instead a kind of fortification. Of being aware of this therapeutic self as a self-created enterprise, made up of parts of the world, the past, the future and bringing it to bear in the present. In a narrative, this would be the middle. The present, if you think about it, is always the middle. And that is where things can turn, that is where it is the most vital job of the hero/ heroine to clarify their purpose, to double down on what they know to be the right thing to do, to sound the clarion call, to clear a path to safety, to create an alliance around a common purpose.
For that is the job of our present generation of teachers and mentors in medicine. To clear the way, to keep them safe, to put a stop to the cycle of violence, to provide safe haven, shelter, reprieve, protection and safe passage out into the world. For that is when the real work begins. When our trainees of the present go out into the world, engage with it, and do so in this new connected era, where they are no longer solitary David to the Goliath, but instead legions bent to rid the world once and for all of the need for monsters.
When only biblical metaphors will do, you know there's work to be done.
So go out and do it. Make your own path through, dare to bring your entire self to bear upon this, for that is the only thing that makes sense anymore at a time when even the doctors are dying.
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