Last week I delivered this talk twice at the American Academy of Family Physicians Scientific Assembly in
Washington DC, and I also presented it to third-year medical students at The Commonwealth Medical College of Pennsylvania. It is fully transcribed here. Every medical student and physician needs this information. Please share widely. You may save a life.
I’m a family physician born into a family of physicians. My parents warned me not to pursue medicine. So I went to medical school. Ten years later, I'm
unhappy with the direction of my profession (and I’m not the only one). Then I get this crazy idea: what if I ask for help? Not from the profession that wounded me. Just from random people on the street. So I hold a town meeting and ask patients to help me—design an ideal medical clinic. I promise to do whatever they want as long as it’s basically legal. That’s going out on a limb.
I’m a go-out-on-a-limb kind of doctor. In med school I protest the dog labs and I’m sent to the office of the Dean—who diagnosis me with “Bambi Syndrome.” In residency I’m caught giving patients recipes for kale salad. I’m sent to the office, reprimanded for not getting approval from the patient education committee. I’m 46 and I’m still handing out unapproved kale salad recipes—now I’m taking on physician suicide. My therapist calls me the “Dr Kevorkian of Medical Taboos.” Before my wedding, my dad actually made my husband promise to keep me out of jail. “Always pushing the limits,” Mom says, “always going out on a limb.” Today I invite you to join me.
Here are the official learning objectives. Bottom line—I need you to take action. I don’t care what you do as long as you do something.
1. Uplift and inspire medical students, physicians, patients, and staff through nonviolent communication and humane teaching methods.
2. Stop bullying, hazing, and abuse of medical students and doctors in the workplace.
3. Intervene effectively with depressed and/or suicidal students and colleagues.
Why do we do what we do? To save lives. Why did you go to medical school? Seriously. Why spend your 20s studying while all your friends are at parties? To make a difference—to save lives. Why are you here? To get CME? See the Smithsonian? Rediscover your joy, your calling? What is your calling? Why are you a family doc? They recruited me for pediatrics, but I kept asking why? Why this kid’s got asthma? Why the parents smoke? Why they live next to an incinerator? I’m a family doc because I can’t stop asking WHY? So why are you here? You had 20 choices, why attend this talk? Maybe you lost a colleague to suicide, a friend in med school. Maybe you are struggling now. Maybe (like me) you just want to know why our colleagues die by suicide at twice the rate of their patients. And you want to save lives.
The fact is each year we lose over 400 doctors to suicide—that’s like an entire medical school gone. I lost both men I dated in med school to suicide. In my town, in just over a year, we lost 3 doctors to suicide. One doc in town lost 7 colleagues to suicide! (In what other profession, can you lose 7 colleagues to suicide?!) This year over 1 million Americans will lose their doctors to suicide. Why? To know why someone has died, we perform an autopsy. With suicides, we perform a psychological autopsy:
Today—for the first time—I share my results from 4 psychological autopsies
This is Vincent. He’s 2. He framed this photo to give his parents at his med school graduation. An adored first grandchild, a joyful little prankster who made everyone laugh. His Aunt Edna told me in catholic grammar school Vincent has his feet up on the chair in front of him. Sister Agnes comes by and tells him to put his feet down. He replies, “I have to keep my legs up!” She asks why. He says, “I have varicose veins.”
Here’s Vincent at high school prom. An athlete and artist, compassionate, sensitive, gregarious, yet private. A compulsive perfectionist. Always a good kid. Never any addictions. Just a straight forward normal good guy, according to his mom.
Here’s Vincent’s med school graduation photo—just 25 years old and 2 months after starting a prestigious surgical residency in New York City, he dies by suicide. Why? Look at his eyes. Notice the difference between his childhood photos and his medical school graduation picture. He looked happy and healthy before med school. What happened during Vincent’s medical training? I interviewed several of Vincent’s family members to find out.
His mom says he became disappointed, disillusioned. He lived near the hospital, but drove an extra 45 minutes home at every chance he had just to sleep in his own bedroom. He lost a lot of weight and his jokes and laughs were gone. His family was concerned, but they thought it was the adjustment to a demanding profession.
Vincent told stories of how surgeons publicly humiliated interns. How he and his partner fell asleep leaning against walls in the hospital while waiting for their patient’s turn for a scan. He spoke of his doubts about saving this one guy who jumped out of a building when caught raping a young girl who was also being treated in an adjacent room. He spoke of the sisters—victims of a car accident—brought to the ER, stunned him for a moment because they looked like his mom and aunt who often travel together without seat belts. Vincent took a belt and hung himself in his closet.
The note he left:
This is Greg at 3.
Outgoing, curious and clever. He always got along great with adults. At 5, he goes on this family trip to visit his great aunt—a nun at a convent. A French professor, she asks Greg to give her a word he would like to hear in French. He says, “Guacamole.”
Greg as a child with his mom.
Greg graduating from med school. A pianist, painter, poet, a real Renaissance man much beloved by his patients. Greg sent this eMail to his parents, both physicians, one year before he died.
Subject: Piece of My Mind
Read this if you have time. It resonated with me especially well this morning. I like these two paragraphs:
“I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many ‘civilians’ would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable.
How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction?”
Greg was the only one in his family who struggled with anxiety, depression, and alcohol. After an outpatient program his third year of med school, he was sober until his second year of residency. A brilliant clinician, never impaired at work, but a Physicians Health Program (PHP) mandated a 90-day treatment facility 300 miles away, where Greg felt marginalized, belittled and was 3 months behind in completing residency. He felt if he were a banker or lawyer he wouldn’t have this forced upon him. He hid his depression and substance abuse and carried a lot of shame. Just 24 hours before his death (he had relapsed), he met with his psychiatrist who arranged admission at a local rehab facility. Greg notified the PHP who held the keys to his license. They disagreed with his psychiatrist’s safety plan. Greg felt humiliated, cornered, and killed himself.
His mom wrote this letter to the editor of The New York Times in response to a physician suicide article last month. You may recall the article about the two young doctors—interns who jumped to their deaths in late August from their Manhattan hospitals. Greg’s mother writes:
“An unacknowledged predicament for physicians who identify their struggle with substance abuse and/or depression is that they are often placed under the supervision of their State Medical Board’s Physicians Health Program. My son, Greg, was being monitored by such a program. He took his own life at age 29, one week before he was to enter an esteemed oncology fellowship. His final phone calls were to the PHP notifying them of his use of alcohol while on vacation, a disclosure he had previously described as a ‘career killer.’
These programs, which often offer no psychiatric oversight, serve as both treating and policing agencies, a serious conflict of interest. Threatened loss of licensure deters vulnerable physicians from seeking help, and may even trigger a suicidal crisis. Medical Boards have the duty to safeguard the public, but the assumption that mental illness equals medical incompetence is an archaic notion. Medical Boards must stop participating in the stigmatization of mental illness. We cannot afford to lose another physician to shame.”
I read 12 pages of online condolences. This anonymous entry stands out: “Thank you for being nice to even the unpopular kids in high school. May your soul rest in eternal peace.” Greg looked out for the underdogs, but what happens when doctors are considered underdogs? Who looks out for us? Do we get the care we need? Greg didn’t. Greg transected his bilateral radial and dorsalis pedis arteries with a scalpel in the bathtub, candles lit, music playing, some wine, vodka, surrounded by family photos.
This is Kaitlyn and her mom.
A sweet, good girl. Kaitlyn never gave her parents any problems, though she cried when she lost at Monopoly. From the time she started preschool, she never needed any help with her homework or anything. At 3 years old, she had to get glasses. Her parents took her to the big medical center where the doctor asked lots of questions. He’d look at the parents for answers, but Kaitlyn answered them all. The doctor was amazed.
This is Kaitlyn in high school. A deep thinker, an artist, a poet. I met her extended family in North Carolina. They claim, “Kaitlyn was one of the happiest people on this Earth.”
Here’s Kaitlyn in med school. Just 23 years old and beginning her third year. An introvert with social anxiety, Kaitlyn always had a few close friends, but none in med school. Everyone was busy studying and “people just went their own way,” she told her mom. She was desperately lonely. Her perfectionism worsened. She went on a strict diet, started running marathons, and lost a lot of weight. She ran like 10-12 miles before class everyday and still excelled in med school, acing her Step One exam. Unfortunately she didn’t live to celebrate her results because she completed her suicide—a helium overdose—like a well-planned school project. She left a 2-page suicide note in which she claimed lifelong depression, but hid it to protect her family and herself.
As an aside, I believe that Kaitlyn suffered less from depression and more from “feeling different and isolated” because of her high intellect. She was raised in the poorest county in North Carolina and was the smartest person around. Maybe she had hoped that when she entered medical school she would finally be with her tribe—a social circle of more like-minded intellectuals. But medical school rarely creates an environment for students to develop intimate friendships with one another. These young sensitive and brilliant people are left to fend for themselves in survival mode with an overwhelming amount of material to master in a short time with little emotional support.
I can guarantee that many medical students cry themselves to sleep at night in their pillows. That’s what I did nearly every night my first year of medical school. I cried so much that one morning my eyelids were sealed shut. I couldn’t see anything when I woke up. I had to feel my way to the bathroom. Is this they way a civilized society trains its healers?
Kaitlyn’s mother published her daughter’s suicide letter in a book she wrote about Kaitlyn.
Kaitlyn’s grieving mother—unable to recover from her daughter’s death—died by helium overdose one year later. I attended her funeral last month.
Here we have a spunky, happy 2-year-old girl who stood up to adults negotiating her way out of a bedtime, a bath time, and persuading her dad to get Slurpees and candy bars for dinner. Life was good until her first year of medical school.
Just a few months into med school she develops major depression due to what she calls “barbaric and inhumane medical training.” Years later, fed up with assembly-line medicine, she’s suicidal. The only difference between these cases is she survived and she’s on stage speaking today for the other 3 who can’t.