If you Google Pamela Wible, MD, you will find pictures of a radiant woman wearing bright makeup and artistic jewelry. Yet, behind those glitter-clad eyes are the revolutionary thoughts of a determined physician who has been trying to improve conditions for health-care providers for over a decade.
Since 2004, Dr. Wible has been helping physicians leave what she has coined “assembly-line medicine” and open Ideal Clinics nationwide. Her model is now taught in medical schools and is featured in the Harvard School of Public Health’s newest edition of Renegotiating Health Care: Resolving Conflict to Build Collaboration.
When not treating patients, Dr. Wible devotes her time to medical student and physician suicide prevention. Suicide among physicians is a silent, deadly and puzzling epidemic happening right under our noses in the United States. Today we are asking Dr. Wible why she believes physician suicide is on the rise, what doctors can do to protect themselves and what patients can do to help.
Dr. Wible, why do you think there are so many physicians dying by suicide?
Well, medical careers have always been challenging with immense pressure coming from all angles.
For one thing, we are steeped in death and suffering. We are the ones trying to save lives. We are the ones realizing that the code isn’t successful, calling it off and having to tell the family that their 3-year-old died. This is a rough, high-stress profession. Physicians witness ongoing trauma and death without getting mental-health support.
What other kinds of pressure are doctors experiencing?
Over the last 10-20 years we have been forced to treat more and more patients due to high-overhead practices. In a giant practice with 90% overhead, physicians have to see 30 patients a day just to pay the bills. It’s production-line, assembly-line medicine that takes all the joy out of the profession.
If you are overworked, seeing death and suffering, having no joy because you’re working at an extremely fast pace just to pay overhead, AND you are struggling to pay back your student loans, some doctors believe they might as well just jump off the roof… which is what they are choosing to do.
Why aren’t doctors seeking mental-health support?
By nature we have to have a certain tolerance for high-emotion, high-drama situations. Plus, traditionally, this has been a profession where overextending yourself for the needs of others is held in high regard. You are the helper, so you shouldn’t be asking for help.
The problem with this thinking is that, as human beings, we all need help sometimes. People in professions that see a lot of death, such as soldiers, police officers and firefighters, can get mental-health support. Physicians see quite a bit of death, too, but don’t seek help.
In fact, if we seek mental-health services, we are punished for it. We have to go before the board of medical examiners and defend ourselves as to why we sought counseling or mental-health services.
Compare how we handle our mental health to how we take care of our dental health. We are taught to brush and floss every day. We’re supposed to go in for a check-up once every six months. We are taught to avoid sugar to take care of our teeth… but what are we doing for our mental health on a daily basis? What kind of brushing and flossing are we doing? If you think about it that way, most of us are not doing anything to maintain our mental health.
To take the dental analogy a step further, doctors are basically eating sugar all day (being exposed to a lot of trauma) and when we get a cavity (for example, anxiety) we get punished for seeking treatment.
Are you saying that doctors are avoiding getting mental-health support because they are afraid of being punished?
The fear of what asking for help might do to your career is a real obstacle. I know a psychiatrist who drives 200 miles out of town to see her own psychiatrist and she pays cash. I think she even uses a fake name. This is the level of fear that physicians have of losing their license for seeking mental-health care.
Even the state medical-licensing renewal forms have a box asking physicians about their mental health—and it’s right alongside the criminal and felony questions. This gives a strong message that it’s not ok to seek mental-health care. There are no questions about your medical history, just about your mental-health history. In fact, physicians have confided in me that they don’t check this box because they are afraid that they will be branded “damaged goods” for the rest of their careers.
The number of doctors who get punished because they have work-related anxiety, depression and suicidal thoughts is just startling. One physician I know, who wanted to get her medical license, checked the mental-health box on the forms because she had received marriage counseling during a divorce. And the state demanded that she give them her confidential marriage-counseling records in order to get her license. Although she did what she was asked, because her marriage counselor had retired, she was forced to get a complete mental-health evaluation with a psychiatrist! Isn’t it rather unfair that everyone has the right to get marriage counseling except physicians?
Yes, that does seem unfair and a bit outdated. Are there other factors that keep physicians from getting help?
I have been informally keeping track of 190 physician suicide cases. For every one female medical student or physician who commits suicide there are 7 men on my list. What I’m noticing in my circles is that male physicians have a harder time asking for help than women physicians do.
It reminds me of how some men, before the days of GPS, would just refuse to ask for directions even if they were lost. I dated a man like this in medical school. He was so upset with me when I suggested we ask for help when we were lost in the car and he has since died by suicide. I bet he never sought the mental health services he needed.
Physicians, with the white coat and the degree, have to have that all-knowing facade, and men have traditionally been asked to be strong at all times, so to ask for mental-health support is really hard for them. Unfortunately, it’s easier for them to just buy a gun and kill themselves and that is what I think is happening.
It is shocking to hear that there are medical students among the 190 cases you are following. What’s happening there?
Patients are very confused about why they aren’t getting good healthcare. To understand why, you need to go all the way back on day one of medical school to find that your doctor was bullied, overworked and sleep deprived. Medical students who are abused become physicians who are abused, and who may even abuse their own patients! This is the cycle of healthcare abuse.
I’ve read that many medical students graduate with less self-esteem and self-confidence than when they started. I think this is really odd. They start as wonderful, well-rounded, bright-eyed, bushy-tailed, idealistic humanitarians and then graduate feeling “less than”. There is no reason to take a group of talented people and make them feel bad about themselves.
Meanwhile, none of us want sleep-deprived robots functioning as doctors. This is the old, militaristic model where the guy who’s the toughest, who can stay up the most days wins. He needs to keep going and stuffing down his emotions. He needs to be a robot.
How would you fix the medical-school experience?
I would really honor medical students and treat them with respect and love, so that they can give back the care they’ve received. If you treat a student like a robot that’s supposed to memorize all sorts of minutiae, you’re going to have a doctor who can repeat all these interesting factoids, but that can’t connect with you.
This attitude goes beyond medical school. Physicians are taught to over give, and be workaholics to their own detriment. Our current economic model is certainly willing to take advantage of people who will work excessive hours: let’s keep the factory workers moving as many days as possible so that we can make a lot of money. Let’s face it, the primary revenue generators in health care are basically doctors. There are many layers of people embedded on top that want them to keep working at faster and faster speeds so that they can make more money off of them.
We are humans, not machines here to do some kind of assembly-line work. We are spiritual beings having a finite human experience and that’s how we need to start relating to each other. We are telling the doctor to be like a machine, and if you’re broken, leave the hospital; you can’t be a doctor anymore.
As a matter of fact, doctors having anxiety may be the best doctors because they’re sensitive and they love their patients. Those are the doctors that you want… people who can feel your pain and are crying with you.
But truthfully, there is not one big-bad entity to blame. We just need to start teaching our healers in a way that is honoring their humanity and not breaking down their spirit. There is a ripple effect. If you want great health care, you need a healer who is well. You need a happy, healthy doctor.
What steps can doctors take to get happier and healthier?
I think everyone in the medical profession should be seeing a counselor once a week or at least once a month because we have enough horror stories to wear out every one of our family members. We definitely need professional assistance dealing with what we are witnessing at work… especially those of us that work in the ER, trauma surgery or a field where we encounter many sudden deaths. Managing the grieving friends and relatives of a patient who has suddenly died is very intense.
It’s important not to use your spouse for this purpose. There is a reason why your spouse works in a Library and not the ER: your spouse can’t handle this stuff. It is unfair to bring all this pain and suffering into your house, and it can destroy your marriage. So you have to take it somewhere else.
What can physicians who are dealing with anxiety and depression do to help themselves?
First of all, they should realize that they are the norm, that the majority of physicians are feeling similar to them.
Once you start to believe that you are defective and that you are the one that can’t handle things… once you compare yourself to all the other doctors who look, from the outside, like they are doing well—then you start to spiral down. You become isolated and withdrawn. You feel like you’re a failure.
The important thing is to realize that you are one of the group! Everyone is feeling stress and self-doubt. You are part of a larger group of physicians who are all suffering and you are not defective. In fact, you are probably strong, because you are willing to feel instead of becoming numb.
Once you’ve made that realization, the next step is to speak to somebody, preferably a class-mate or another physician. It’s just like soldiers who’ve been to Iraq or Afghanistan and are suffering from PTSD. They do better speaking with someone who’s also been there, versus trying to explain things to a therapist who’s never left the U.S.
For physicians, it’s comforting to be able to speak to someone who says “I know what you’re going through. I went through the same thing and I’m fine now because I did this, this and this”. Reach out to peers or even a support group that contains other physicians. Sometimes when physicians realize they are not alone they are validated and feel better.
What if this is not enough?
If this is not enough, then it is important to seek professional help. You might need a psychiatrist, you might need antidepressants, but you have to take care of yourself. Don’t let yourself start to spiral down.
In addition to seeking mental health services, I recommend creating a support team. This could include a massage therapist, a church pastor, a life coach, or even a hairdresser… whatever works for you. It’s important to make seeing your support team part of your ongoing, self-care routine.
It’s also very important that you take your life back and find some balance. You need to learn to say:
“No, I can’t stay, I am getting 8 hours of sleep tonight.”
“No, I can’t work later, I am going to leave at 5 o’clock because I need to go to my son’s middle school graduation.”
“No, I’m not working any additional hours this week. I have a life outside of medicine, and if I don’t nurture it properly, I will not be a very good doctor. I’ll be miserable because I haven’t seen my wife, and I haven’t seen my kids… and I don’t want to lose my family!”
How can patients help?
It would help if patients took more control over their own health. Over the years we’ve groomed patients to become whining, complaining, begging juveniles. We’ve been in this very strange hierarchy where the doctor is the know-it-all parent and patients beg for help like little children. That model is exhausting for the doctor and debilitating to the patient. When an adult goes to a doctor this should be a peer relationship.
Patients can try to treat physicians as humans, not gods. Physicians may know more than patients about the human body, but they are people too. Seeing a doctor should be like seeing the CPA or the car mechanic. We all have our own skill sets and we’re all adults.
Patients should do their own research and be prepared. They need to select doctors that want to engage with them as human beings. When we create this peer relationship, it takes pressure off of both parties. In fact, when we are adults with each other and treat each other with respect, we can heal all of our relationships.
Beyond that, patients can apply the Golden Rule by treating physicians the way they would like to be treated. They can be kind. They can take the time to say “thank you”.
Is saying “thank you” important?
Physicians have suffered for so long that even when a patient says “thank you” I don’t think they really take it in and feel it. Even when they save a life, I don’t think they take a moment to think “Wow, I just saved that person’s life.” When somebody dies, I don’t think they take a moment to be in awe of the mystery of life and death. They just keep going, like automatons.
As a patient, you can jolt your doctor out of that robotic mode just by telling them how much you appreciate what they’ve done for you. Take a moment just to say “hey, what you’ve done has really made a change in my health/life/marriage this year.” Sometimes a simple thank-you card can do the trick.
The media has been strangely silent about physicians dying by suicide. How do you think we can bring more awareness to this problem?
I believe that as individuals we need to talk more about physician suicide and bring it out into the open. I hope the Internet is going to bypass traditional media and that the public’s need to know the truth is going to bypass any media’s need to cover it up. We are at the stage in our progression as humans where we really want to connect and be one world. We all want Heaven on Earth. In order to solve the problems of the day, we need to know what they are.
You mention wanting Heaven on Earth… how can doctors use their own spirituality to help themselves?
To be able to function like robots, physicians turn off parts of themselves. There’s a perception that love, hope and emotions are just fluff, and that being emotionless equals strength. Instead, we are finding out that being human and vulnerable makes us much stronger psychologically.
What kind of life are we living, in silent desperation, as just parts of ourselves? If you are just breathing in and out, and you’re the shell of the person that you once were before you entered medical school as an idealistic humanitarian, is it really worth continuing to go through the motions, completing tasks, checking off boxes and fulfilling algorithms? That’s not really a life.
As a society we need to get back into our bodies and our souls. In fact, I think we have to bring our souls back into our bodies, all of us. Some of us already know how to do that. At church where we are willing to open up our souls and our hearts and be silent for a moment—in awe of the universe. Unfortunately, when church-time is over and it’s Monday morning, it’s time to get back in the speedy-brain mode. It’s important for us physicians to stop and take moments of silence during our work week. It helps integrate us. We become fully human and we can love our work and each other.
In fact, we can even take that pause at the beginning of each new appointment. We can, for 30 seconds, stop the chatter and the codes and the software to just be together in that sacred relationship between the healer and the patient. It’s important to realize that although we can do lung transplants and all sorts of amazing procedures, without the healer/patient relationship, none of this would be happening.
We can take a small pause to be silent together, to connect to the world and each other with our souls because some of this goes beyond words. By doing this, we can bring back that child-like wonder, awe and appreciation for life.
To learn more about physician suicide, abuse and bullying:
To learn more about the Ideal Medical Care Movement: