The Dark Side Killing Doctors

Eric Levi outlines the Dark Side of Doctoring in one of the most important health care topics of our time. He was led to this blog post after another physician took his own life. The words of the widow of the physician to trace the final steps leading to this tragic loss. These words have the power to help others to understand the process that leads to death for those pledged to life.

The following represent a number of resources for physicians and their families as they struggle with the Dark Side. Advice comes from the blog, the widow, 5 Regrets at the End of Life, The Antidotes of Stress, and what we should do as physicians and as a nation.

The formula is not difficult to understand - Too little sleep, too many life interruptions, too little time left for family or self, feeling too important, finances too complicated, feeling too inadequate, and eventually leaving too few indications of the final act to come. 

Exhaustion, interruption, marginalization, superhuman expectations of self and others, and neglect of the basics represent great challenges individually but are worse collectively.

The Big Three - Rapid Changes in Multiple Dimensions
  • Loss of Control - too many bosses, including those that cannot be accessed. There are no negations with those who make policies, set contracts, and force behaviors. The recent changes in medicine make matters worse. Physicians are less and less independent and more likely to be employed. Graduation comes with much higher debt load. This debt will require years and will control job and other choices. More control comes in smaller or independent practices but these get paid less by design. Better payments go the the largest systems and practices, where individual physicians matter less. More will be part of large and impersonal and poorly responsive.
  • Loss of Support - Support declines complicate the accelerations of too much to do. In previous generations of physicians, the spouse was able to be more supportive. Now physicians are more likely to marry a physician, a nurse, another person delivering health care, or another person with a career and a life of their own.
  • Loss of Meaning - The physician pledge to put care of others before self comes with consequences when so much else is inserted. Menial tasks and numerous training modules are required, the same ones year after year. These are easily recognized by those experienced in health care delivery to be of little relevance to patient care. 
Physicians can be replaced by nurses, nurse practitioners, physician assistants, or other physicians. Loss of control, loss of meaning, and total loss of support are very real and very challenging to address.

Female and newer graduates have indicated that family and personal life is more important - making loss of control, lack of support, and loss of meaning more difficult.
Physician lives have always been divided into too many pieces. More pieces have been added and these pieces added have been replacing everything else.

Loss of Control

Policies and procedures required by government designers and insurance payers have been allowed to marginalize nurses, physicians, and all who deliver health care. Regulations have increased, approvals are required, data must be collected. Dollars distracted from those who deliver care takes time and energy away from patient care and from those who deliver patient care. 

It costs so much to do more that less time and energy is left to address patient needs or the needs of those delivering care. There is a reason why this is called meaningless change. It is meaningless except for those delivering care in which case the appropriate term is just plain being mean.

Anti-Support from Health Care Associations

Physician associations are failing in numbers of members and the support given associations by members. They fail to represent most of their members for good reason. They have failed in major areas important to physicians. They have failed to obstruct the efforts of those who have taken away the independence of physicians - most important for physicians to have some control over how they are treated and more importantly, how their patients are treated. 

Even worse, associations have added to certification burdens with meaningless Maintenance of Certification - evidence based only for more dollars in the hands of those that run associations.
  • Depressing Theme in Health Care: We are health care designers and we are here to help you if you do not mind more micromanagement, less independence, more time before and after work to complete our tasks...
There is increasing recognition by those who deliver health care that they are  

Pawns of the For-Profit World and
Others Not Caring for Patients

Being Replaceable - A Constant Reminder That You Do Not Matter 

Physician expansions involving numerous sources mean more competition and less independence. You can be replaced. Someone else will put up with what you may not want to deal with. 

Initially nurse practitioners and physician assistants were seen as important team members in rural, underserved, and primary care practices. But they have long moved away from such practices to more specialties with more added to each new specialty. They work with physicians in offices, hospitals, procedural facilities, and other settings. Fewer physicians are needed of all specialties. Less costly clinicians can reduce the number of cardiologists or neurosurgeons needed by doing the non-procedural tasks. In turn, too many nurse practitioners impact upcoming NPs and their support, control, and meaning.

In some settings, the challenges are not about replacement. The challenges are about financial survival, annual raises, benefits, having enough team members, and other problems caused by the grossly inadequate payment designs across primary care, mental health, and basic services. The real problem in these practices is inadequate payment. MD DO NP and PA are marginalized in primary care and in other lowest paid basic services. 

Loss of control, loss of support, and loss of meaning are all facilitated by too many graduates regardless of payment for some while others struggle from insufficient payment.

Misguided Flawed Research

Many physicians still believe in the validity of today's research and what major journals publish. Their faith is misguided. The research errors are many and significant. Many are while male older physicians such as myself - all of these categories are blamed for problems by the research, especially BMJ publications. Almost daily one or more of my categories is blasted in the media. The following are constantly blamed for one ore more ills regarding health care. 
  • Physician
  • Older physician
  • Male physician
  • Lower volume
  • Rural or lower concentration location
  • "Medical" errors
  • Too little time with patients
  • Too slow in accepting technology, innovation, measurement focus, digitalization, mindless changes, heartless changes, or meaningless use and abuse
As I have outlined in numerous critiques of these articles, most of these studies should not see print or if they do, there should be more words about limitations than the rest of the article combined. Also there should be no speculation - the major fuel that gains promotion and distribution. 

Studies demonstrate that one of the worst sources of speculation involves the press releases of the institutions of the researchers. The press releases of associations are often not much better.

Not everyone has the ability to see through the research drama to the flawed techniques, the lack of hypothesis (witch hunt), the lack of specific data collection for the purpose of the hypothesis, the lack of exploring alternatives, the lack of limitations, the assumptions, the cherry-picking of findings or references, or the agendas of the journal or tendency for the dramatic or support of current bandwagons. 

There Are Research Findings That Are Important

Studies demonstrate more time required for EHR, too much cost of Primary Care Medical Home, more digital distractions, decreased morale, increased burnout, and decreased time with patients. But this fails to gain much print or promotion. 

It is not hard to see team members targeted by measurement focus, digitalization focus, quality improvement, cost cutting, higher complexity of patient, and higher complexity of health care. Why would a local practice hire a practice consultant to help them address quality - someone who does not understand local patients, populations, resources, situations, environments, behaviors that actually shape health outcomes? Why does it cost $80,000 to 100,000 more per primary care physician to be PCMH to improve process but not to be able to impact outcomes? Why focus team members upon measurement and protocol and away from working with the community and patient needs?

How hard is it to see that studies where there are comparisons with one cohort demonstrating better outcomes because their population has better health indicators (volume, rural vs urban, PCMH)?

Why is it so hard to see that studies with same or similar patient populations demonstrate little difference in outcomes (NP vs MD, Resident Work Hours Before and After, Pay for Performance)?

Why is it so hard to see why insurance companies, ACOs, large health systems, and others use strategies to cherry pick the patients with the best outcomes in ways that small and local practices cannot?

Triple Aim focus, Digital Focus, and the Perfect Storm of too little payment for too much required from too few are helping to make those who deliver health care sicker or dead - loss of control, loss of support, loss of meaning.

For those few such as myself that realize that health outcomes are mostly about people, populations, local situations, community, and other non-clinical factors - it is indeed a difficult time. The ways to improve people are about changes specific to people impacting them 24/7/365. It is not about those who spend a few minutes with people as residents, as physicians, as nurse practitioners, as physician assistants, or as nurses.

There is very little that can be done to improve health care outcomes from inside of health care. But there is Big Health Business demanding more to be done and more to be paid to corporations to do it.

The real changes have to occur in people, behaviors, environments, situations, relationships, loneliness, falls, impatience (driving too fast, running late), housing, nutrition, caregiver support, local resources, child development, and support for those under extremes of stress. 

Physicians and Patients - Sharing Loss of Control, Support, Meaning

It is not a surprise that physicians and their patients often share the same loss of control, decreasing support, and loss of meaning. As long as patients experience loss of control, declining support, and loss of meaning they will be failing - and often this is failure by design.

Patients and their physicians are experiencing post traumatic stressors - and neither have access to those who can identify, evaluate, or bring supportive resources.

I am pretty sure that one of my jobs came to a close because I was identifying too much with patients who were experiencing lack of control, support, and meaning. There was substantial impact upon me in ways difficult to understand. I learned much from the Balint support groups meant for residents, but helpful for faculty as well.

Physicians Observing Care of Family Members or Self
As a physician, it is difficult to see what has happened in health care - especially when you bring your father or children or other loved ones in for care. I understand why so little time is spent with my loved ones - but it makes me hate what has happened all the more.
The widow of the departed physician wanted to share the turmoil in the hope that some will avoid this in the future. 

She has already delivered on the promise of hope to come. The comments on the blog reveal the help already on the way.
  • I struggled with the demands from the beginning. I always thought it would get better. It hasn't. 
  • One female physician read the blog and widow's story aloud to her husband - who broke down in tears. None are doing poorly at what they are doing. They are all being asked to do too much with too little for too long.  
  • Some related stories of being a physician and going through depression, postpartum depression, loss of relationships or family members.
  • "Any kind of emotion other than pleasant subservience makes you a victim of gossip rumor and innuendo – particularly if you are new to a place, and then their is the added pressure of having enormous responsibility with zero familiarity with systems and no account taken for how much longer it will take you to perform and complete administrative tasks. I am battling depression for being vilified for doing my job extremely well and not caving to pressures to cut corners and compromise. Rashmi is right. One wrong event early on will set off a chain of events.
  • Some were reminded of traumatic events in residency or in practice that led to career, family, and other changes - but the blog gave them a perspective that they did not have on what happened and why.
  • Some noted the focus on best practices would be nice, it the time and resources were given for such a lofty goal.
  • Some indicated patterns of abuse.
  • Others watch as the help that they need is sent home or is not sent at all - due to cost cutting measures or policies that make sense only to those thinking about money and not about people, patients, or health care.
  • Busier and busier, pushed and pushed, more done on unpaid time...
  • "No one ever checks to see how ‘good’ you are at your job – which is caring for your patients and their being satisfied with the care that they are receiving."  C Card Frankly no one ever checks at all. There is little notice, other than perhaps a meeting to discuss occurrences which were largely outside of the control of anyone. 
  • "All I ask is that people don’t play the world’s smallest violin to me when I whinge about little things in my life whilst I hide the dark side of doctoring behind my smile." - by SmallViolin

I apologise for the group email but I wanted to thank those of you who have been so kind with your messages and thoughts over the last three days.

Apologies also for the length of this email but it is important to me to let you know the circumstances of Andrew’s death. Some of you may not yet know that Andrew took his own life, in his office, on Thursday morning. Andrew had never before suffered from depression. He hadn’t been sleeping well since late February; but he was never a great sleeper. He was very busy with work; but had always been busy. Just before Easter he became anxious – about his private practice, about being behind in his office administration, about his practice finances, about some of his patients, about his competence. He seemed very dispirited and non-communicative. I did what I could to help where I could, but I was confused – he’d always been busy and the practice, as far as I could tell, was running just as it had for the last 20 years. He was flat all Easter and, the week after that, he was on call for the public hospitals. It was one of the worst on call weeks that he had ever had – he was called every night and some nights more than 3 or 4 times and during the day he had to see his own patients and do his endoscopy lists. He missed our sons birthday dinner and every other dinner at home that week.

By the end of the week he was exhausted, still could not sleep properly, and was just flat. I was very concerned about him, tried to talk to him about my concerns, but he was very unresponsive. I urged him to go and see someone about his sleeping but he was non-committal. He continued to see patients, do lists, go to work, get home late.  On Tuesday evening he was upset and teary because a patient had died. Andrew was always upset when any of his patients died, but his level of distress in this case was unusual.

In retrospect, the signs were all there. But I didn’t see it coming. He was a doctor; he was surrounded by health professionals every day; both  of his parentswere psychiatrists; two of his brothers are doctors; his sister is a psychiatric nurse – and none of them saw it coming either.

I don’t want it to be a secret that Andrew committed suicide. If more people talked about what leads to suicide, if people didn’t talk about it as if it was shameful, if people understood how easily and quickly depression can take over, then there might be fewer deaths. His four children and I are not ashamed of how he died.

So please, forward this email on to anyone in the Wilston community who has asked how he died, anyone at all that might want to know, or anyone you think it may help.

Support for Patients, But Not Team Members

The Geriatric Emergency Room and Hospital proposals were interesting. What they proposed for these places was better sound proofing, less interruption, and other environmental improvements.

These would be a great idea for the team members who are working there and need better environments all the time that they are working - and better support for what they do.

Above my work desk currently there is a sign offering me support regardless of where I work and at any time.It promises all the information and support that I would need – for EHR.

Signs of the Times - Today

AAFP Celebrates Family Doctors, but...
Celebrating you today (and every day)
Happy World Family Doctor Day! You are an inspiration to your patients and community today and every day. One of your most important skills is the ability to actively listen to each patient’s needs. For that, your patients trust you and turn to you for guidance.

In honor of World Family Doctor Day, the World Organization of Family Doctors (WONCA) has named depression this year’s theme. To assist you in future conversations with patients, we’ve gathered a variety of depression and other mental health resources to access.

We hope you take a moment today to reflect on how your work makes a difference.

Again, thank you for all that you do for your patients—both body and mind.

Reflection is important, on what is going on in so many ways that indicate loss of control, loss of meaning, and loss of support. More than a card or web site is needed. AAFP also wants us to support new meaningless promotions and campaigns with interesting names such as Thunderbolt, generic support for primary care, and prevention campaigns. What about supporting us?

We need more support for nurses, teachers, police, and team members across primary care, public health, urgent, emergent care, and those stretched too far and too fast and too long. The jobs are getting more complex, the demands for time and additional efforts are increasing, the risks are greater, and the support is not sufficient to the challenges.


The Example of Too Many Graduates from Too Many Sources

The actual result of MD DO NP and PA expansions is entirely about non-primary care workforce contributions. NP and PA have established more new specialties with more added in each new specialty. This has not been difficult as the largest systems and practices have long seen value in this. The versatile NP and PA graduates have become important team members in specialty, subspecialty, office, and hospital settings. This results in fewer of the most costly physicians needed. This moves the subspecialty physicians to more of the highest paid procedures, but fewer are needed.

There are already too few physicians to be able to share call in subspecialty areas. With fewer needed, the call and the interruptions can be worse. Ideally there are 4 or more physicians of a specialty to share call. Perinatal specialists may have to cover 3 hospitals with only 3 physicians in some cities. Teams with 2 physicians, 2 nurse practitioners, nurses, and other team members are replacing 3 and 4 physician practices. Time on and off become more difficult.

There are many other problems arising from a rapid, massive expansion of workforce. Nurse practitioner expansionists have clearly not thought this through. Too many graduates 
  • Will saturate the workforce and related workforce areas. Slow steady expansions are best for workforce. Each 1000 annual graduates results in 20,000 to 30,000 more in the workforce. This is a 20 - 30 times multiplier with full maturity at the new level and is substantially higher with continued expansion. 
  • As the graduates age and long before they are ready to retire, there is no room for newer graduates. 
  • The 20,000 a year for NP graduates if sustained will result in 400,000 to 500,000 who could be active NP workforce.  The PA graduates can have longer careers and 10,000 annual graduates results in 300,000 for a workforce - if there are no further expansions.
Expansions are not about solving workforce problems. Expansions have taken on a life of their own. Studies of future workforce and special centers have been proposed to address these areas. Unfortunately what is most important is an understanding of the consequences of rapid expansions and too many graduates. 

New announcements of new medical schools are not good. Those that promise more primary care are lying because the financial design prevents increases in primary care positions and team members. Such a new school or program may indeed produce more who train in primary and even more who enter primary care, but this may not result in more primary as they are forced to depart. The result within a state or nation may well be displacement of others from primary care for no net gain. 

Traditional medical school building should end. There should be reductions of international graduates as well as Caribbean graduates. The NP and PA expansions should also stop to address 
  • loss of control, 
  • loss of support, and 
  • loss of meaning
Foundations Undermining Physicians, and Clinicians 

Assumptions guided the development of ACA and the resulting micromanagement and lack of help for lowest physician concentration counties. Assumptions guided managed care reforms. The same mistakes were made twice. 

Foundations who say that they are focused upon health access and better health care have funded new sources of workforce. There have been assumptions that physicians are replaceable while ignoring the fact that too many graduates makes all MD DO NP and PA replaceable. 

Government funding has been a major factor in the massive expansion of workforce. This supports those who profit from training, training that often is lacking in faculty (due to loss of control, support, meaning for faculty). This government expansion support undermines existing workforce and support for workforce. 

If this is not clear, examine the efforts of health insurance foundations such as United Healthcare to see the substantial support of alternatives to physicians. Sadly the massive increases of nurse practitioners from 1500 to over 20,000 annual graduates since 1980 has worked to marginalize nurse practitioners along with other sources. Physicians have been undermined. This is most obvious in the rural located major health systems such as Marshfield and Geisinger. There has been shrinkage of the physician workforce - replaced by massive additions of new team members following the dollars shaped by payment design. And the outcomes - well it turns out that these places had better populations - essential for better outcomes. Mayo was the first and the massive dollars entering Mayo changed the entire region, which already had better outcomes due to best child development and other factors impacting outcomes from birth to encounter.
Mental Health That Understands Toxic Situations and Relationships

One comment involved the TV show MASH. There are many times I would like to talk to Sydney the Psychiatrist - obviously another who was barely making it day to day as noted in the show. What set MASH apart was the physician and other advice that made the show real and relevant. 
What if we had the mental health that we needed when we needed it - 
  • Major Sidney Freedman in MASH -
    Capt. Benjamin Franklin "Hawkeye" Pierce: So when do my nightmares end?
    Dr. Sidney Freedman: When this big one ends, most of the others should go away. But there's a lot of suffering going on here, Hawkeye, and you can't avoid it. You can't even dream it away. 
  • Someone who listens, and probes, and cuts through the BS is necessary.
  • Robin Williams in Good Will Hunting, Sean: "You think I know the first thing about how hard your life has been, how you feel, who you are, because I read Oliver Twist? Does that encapsulate you? Personally... I don't give a shit about all that, because you know what, I can't learn anything from you, I can't read in some fuckin' book. Unless you want to talk about you, who you are. Then I'm fascinated. I'm in. But you don't want to do that do you sport? You're terrified of what you might say. Your move, chief."
  • Ultimately people, patients, and physicians have to make tough decisions. These decisions can involve the way that they relate to others, or choose not to do so.
  • Dr. Dix is the policeman turned psychiatrist in the Jesse Stone series with Tom Selleck - Dr. Dix related the worst day of his life as a cop, and his last day as a cop - "Nobody knew what I did. I went home, pounded a fifth of scotch, passed out. I woke up with a hangover and a revelation; the job and the drinkin' feed each other... toxic. 
  • Dr. Dix to Stone: You figure it out yet?
    Chief Jesse Stone: I don't think it's the kind of thing where a light-bulb goes on.
    Dr. Dix: Is it Jenn, or is it the work that makes ya' drink?
    Chief Jesse Stone: Hell I don't know, could be both, I'm not a shrink.
    Dr. Dix: I prefer 'therapist'. When you're on a case you don't drink.
    Chief Jesse Stone: I always drink; if I'm involved I don't like to drink a lot.
    Dr. Dix: You once told me you want to kill her boyfriend, did you mean that?
    Chief Jesse Stone: I was jealous.
    Dr. Dix: That's not much of an answer for a shrink.
    Chief Jesse Stone: Jealousy isn't a good enough reason?
    Dr. Dix: Jealousy's a powerful thing. What I want to know is, do you think you meant it?
    Chief Jesse Stone: I meant it.
    Dr. Dix: So if you could've gotten your hands on him...?
    Chief Jesse Stone: I'd've killed him.
    Dr. Dix: Jealousy's a powerful thing."
    Dr. Dix had a good understanding of the patient, his condition, his alcohol, and the toxicity of job and alcohol. We all have toxic areas to address.
Someone who understands what you do in your occupation, how you got there, how you could go too far, and is willing to work to help you not to go too far is important.

Mental health work is quite complex and poorly supported with lack of control and often meaning can also be lacking. We should appreciate the work and the workers more and demand more support for what they do. 


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