Physician Burn Out and Suicide

I often feel alone.  Like a soldier on the front lines.  I’m working in clinical medicine with patients increasingly desperate with the lack of physicians and waitlists.  Of course I sometimes believe we have the largest bureaucracy in the history of health care with Committee Cancer and all the other waste of mismanagement.

Pamella Wible MD has been studying physician suicide.  Apparently our ‘perfectionism’ and ‘conscience’ are problematic especially when we aren’t given the support to achieve the unreasonable expectations of patients and leaderships. Increasingly the patient wants us to heal them while the authorities want us to do the least at the greatest saving to the system.  It’s like being a soldier again, on the front line, and they are handing out 3 bullets and telling us not to shoot.  The patients always turn their attack on the physician they see because the elite are so far removed in Space Stations feeling their Ivory Towers were no longer safe.  

It was great to learn too that the ‘disruptive physicians’ are indeed being scapegoated in most cases for the broken system. The principle problem is indeed the ‘blame and shame’ management of administration. Rather than address the crisis they persist in their antiquated 19th century management approach to law and administration by standards ‘cover your own ass’ bureaucratic strategizing and looking for an ‘indivdual to blame and shame’.  

The burnn out figure for physicians is 40% and often more than 50%.  That means there are literally hundreds of thousands of burnt out physicians functioning all across the US and Canada.  These are primarily the people in the front line. The worst hit are emergency doctors. The quip on the tape was ‘you don’t see many 60 year olds practicing emergency medicine’.  Dermatologists are by contrast fairly happy like pediatricians because of job satisfaction and reasonable re imbursement. As long as I’ve worked their has been ‘wage control’ on doctors with all the savings of our increased training education and skill being skimmed off to pay the outrageous costs of swaggering smiling CEO’s.  Burnt out physicians are at highest risk for making mistakes, depression, suicide and alcoholism.  No surprise, the ‘stress’ of the work causes addiction behaviours.  Not vice versa. PTSD is prevalent and it was found in the military the guy who bayoneted the other guy was at highest risk of developing PTSD and a third of these front line folk got addiction disease without any genetic contributions being found.  So despite what the ‘suits’ say it’s tough seeing patients.  The least likely to suicide are those in administrative medicine and doctors who have least contact with patients like radiologists or lab doctors. I expect pathologists have a pretty good gig too. 

But of course, the ‘blame the victim’ mentality prevails.  Instead of compassionate consideration that there is an endemic and epidemic stress level individuals who speak out about the gross inadequacy in leadership and often actual corruption these ‘whistle blowers’ are literally hounded and punished severely to maintain the delusions that the ‘emperor has new clothes’.  A brilliant study of the last Liberal Ontario Provincial government showed that the administration literally wasted ‘billions’ of health care dollars  by having a little chair shuffle on the Titanic.  No improvement in health care before or after the several years of changing names and meeting places for the duplication and triplicating of self serving leadership.

The suicide rate in the military was considered an epidemic when it rose past  23/100,000 but doctors are dying at a rate of 40/100,000.  And all they get is ‘blame and shame’.  They are also encouraged to exercise. 

The reason I’m happy to hear this is because I’ve been reporting the ‘systemic’ problem and the gross mismanagement of resources for years with constant back lash sometimes by individuals actually diverting clinical care money into their own pockets.  All the while I’m told I’m a bad doctor and that I shouldn’t  swear.  (I’ve been known to pull out my hair and scream ‘fuck!’ Or “I”m not going to take this shit anymore.    I love my female colleagues who have taken to keening in the hallowed halls.  We’re considering consulting those fellows who have learned to talk with gophers, chimpanzees and dolphins and such in the hope that they might learn how to communicate with management.   We need a Star Trek Unversal Translater or a Hitchhikers Guide to the Galaxy Babblefish because they don’t seem to be hearing the screams on the people.  “Give them cake,” is no longer a good answer even if today the new twist is  ‘Give them pot’.   There one skill appears to be pointing fingers and apparently they are selected for this one quality.  These are people who haven’t seen a patient in decades, see selective patients from Potempkins Villages  and are surround  themselves with echoing sychopahts., so out of touch with clinical reality as to be deemed psychopathic or psychotic, all the while Rome burns and Nero plays his violin.

Yesterday I listened to this presentation driving the 1/2 hour commute to and from work that because of the construction and bike lane chaos in Vancouver is now 2 hours making my previous 9 hour day job 13 hours a day.  

So I have hope.  Maybe physicians can finally stop metaphorically pouring gas over themselves and setting themselves on fire to bring attention to the systemic failures. Dr. Robert Hare studied Corportate Leadership to address the tendency for certain types of systems to promote sociopaths to leadership. The problem too was ‘bullying’ by physician leaders of physicians. This same problem had been noted in police organizations.  Wow.  Someone is  seeing the envy and petty small mindedness for what it is and naming it and actually looking for the ‘identification for the aggressor’ types who make the best ‘Capo’s’,  a term used to describe management strategies used by the Nazi’s. 

  

One step a head of the crowd and you’re a leader, two steps ahead of the crowd and you’re a martyr. I was thankful hearing the presentation as I felt less like a voice crying in the wilderness. The American Medical Association is putting millions into addressing this problem now and the take home point was simply that the whole of the present health care system was about to collapse unless management did something to address their own inhumane abuse of physicians.  In my minds eye I saw the German Army in Russia in winter and Hitler shooting the ‘messenger’ who told him ‘you have to send the troops overcoats.”  It was said that the British won the war because they cared for their people.  

I have hope.  Despite the commute, tt was a good day in the clinic.  

Medical Professionalism Charter 2002

Lancet and the Archives of Internal Medicine in 2002 published the Medical Professionalism Charter 2002 renewing committment to patient care as primary, committment to patient autonomy and a committment to social justice.  Harold Sox, Annals of Internal Medicine, Feb 5, 2002.
I studied community medicine and public health and served in the areas of greatest need. I wrote a paper on Social Responsibility for the Canadian Journal of Psychiatry. I served in the north where doctors simply would not go and in asylums where psychiatrists couldn't be recruited. I worked pro bono for years in many areas and with the dangerously insane and the infected and questionable.  I got on well with doctors who had done missionary service. My colleagues who were most successful and most lauded in awards and promotion were highly particular about concern for the richest of patients.  Indeed, the doctor to the king, has always gone a lot further than the doctor to the poor. I've been an outsider stigmatized with the same stigma that my patients experienced.
Now I see that 'social justice' is part of the 'new world of order' in the 'profession'.  Irks me, considering how much heat I have taken personally for championing lost causes and fighting for the disenfranchised and going where doctors wouldn't go.  I was told by one of the head doctors in the Canadian Medical Protective Association that I was the most persecuted doctor they knew while at the same time I was told by a former head of the Canadian Medical Association that I was possibly the only  psychiatrist with integrity in the province.
I muddle along.  I love medicine and the practice of medicine.  I daily though seem to be fighting government for services for my patients, patients who as ignorantly as I assume those services are available to them as part of the social contract and the taxes we pay.  There have been no elective hospital beds and no nurses and demands for everything political but health care.  I feel like a cop who goes from fighting crime to guarding parking meters.
The charter makes a committment to patients, a committment to honesty with patients, committment to patient confidentiality, committment to appropriate relationships, with patients, committment to improving quality of care, committment to improving access to care, committment to just distribution of finite resources, committment to scientific knowledge, committment to maintaining trust by managing conflict of interest, committment to professional responsibilities.
It has been my experience the authorities pay lip service to the 'committment to honesty with patients."  It's a crock. My own experience and the experiences of my patients testify to the hierarchal dishonesty in the system. Twice I have had doctors lie in their care for me to cover up their errors and save their asses. It's a routine failing in the system.  I have witnessed it routinely.  It's as if there were two ledgers in the health care system, one for the patient to read, and one for the authorities. The same system applies in the baurocracy with secrecy and close doors and clandestine discussions.  Until there is a 'culture of honesty' there will only be the appearances in this regard. The reason I am following the Julian Assange case and Wikileaks is that it speaks to our very own governments real position on honesty to those who are served.  There is too much power in secret societies to expect this to go away with flowery words.
Committment to just distribution of finite resources - I can be committed to anything but in the end the rich and powerful get the kidneys or whatever. No one I know is standing in their way and all of the beaurocratic authorities have been there to assist in this.  Committment to scientific knowledge seems to be mostly whatever scientific knowledge is fashionable.
I am hopeful regarding conflict of interest.  I was forever getting into trouble objecting to the conflicts of interests in patient care. People were doing all manner of dirties locally and I was getting into all manner of trouble bringing it to the attention of the authorities. It was al most like 'no publicity is bad publicity'. Caught red handed the perpetrators of heinous wrongs went right on doing them at increased profit.
Now I don't see this so much.  Partly because I've taken to looking the other way like most of my colleagues always did.  Partly because pharmacists are calling themselves 'professionals' and people are expecting them to act in a less cavalierly tyrranical manner than they have to date so the heats off the doctors and moved to the pharmacists and perhaps others in the system rich on conflict of interest.
Committment to professional responsibilities is a vague thing. The more I 've been committed to my profession the more I've been criticized.  As a specialist and subspecialist I've devoted another 6 or more years of loss of income and study to being trained at best for my patients while my colleagues who didn't do further training remained with position authority and gained more money and power. Today it's common to see the highest ranking professional being ordered about by the lowest common denominator in the health care system. The patient and the doctor are least welcome too often.
I think the charter is a good thing. I wonder about the language. It seems a lot of work and yet it doesn't appear to add much to the code of ethics for physicians . I am not sure I agree with words like 'justice' being used in medicine given such short thrift the word got in legal circles. Blind judges are one thing but blind surgeons are another.
Since 2002 things don't seem to have got much better in the patient care area despite this fine manifesto and I fear mostly there are fewer and fewer hands to do the work while more and more people seem to be getting paid vast sums to talk about the problems of the patients.
That said the charter overall seems fine unless it is used as too many such papers have been used, to beat doctors and deny patients. The devil is in the details.