Disposable Doctors

When I started practice a little more than a decade ago, I got on staff at our suburban community hospital. With my shiny new diploma fresh out of training, I was probably more than a little condescending, having been taught at the big city academic medical center (BCAMC) where I trained, that REAL cutting edge medicine could only be practiced at BCAMCs.

Fortunately, I was knocked off my ivory tower , brought down to earth, and saved on what would turn out to be many, many occasions, by my favorite ER docs. These guys had battle experience, having worked in big city hospital ERs, they knew the patients, they had smarts, and heaps of common sense. Aside from taking care of a never-ending stream of patients, they also had to constantly beg for admission beds, cajole cranky consultants to come in, and sweet-talk the lab or radiology to speed up that blood test or CT scan. When I got that 2AM call from a wheezy asthmatic, all I had to do was send them to the ER and I could rest easy that my patient would be well cared for until I got there. We were a team, and I never even thought what it would be like without them to rely upon.

So, I was stunned when I heard that these wonderful doctors, who had served our community well for more than 10 years were being fired! Why? you may ask, and I asked the same question. The reason given was that they had not done a residency in Emergency Medicine and did not have ABEM certification! Now, please note that the ER docs in question had done residencies in Internal Medicine and Surgery and had board certifications in these specialties and/or were certified by the ABPS, and more importantly, WERE EXCELLENT ER PHYSICIANS AND HAD DONE AN OUTSTANDING JOB FOR MORE THAN 10 YEARS! Why would the hospital be one day happy with their services, then next day suddenly dispose of them like used Kleenex? Well, apparently the hospital CEO decided (without consulting the medical staff) that he would like to “improve” the ER by contracting with an outside company that would bring in their own doctors, none of whom we knew or ever met, but were ER residency trained and ABEM certified, and they did not hire non-ER trained ER physicians, thus our old ER docs were OUT. It is heart breaking and shameful that after devoting a significant portion of their lives and careers to this hospital and community, our ER docs were dismissed, (as if talented experienced physicians are so easily replaceable), through no fault of their own.

Apparently, this episode is not so uncommon nowadays. Nassau University Hospital planned to fire all of its ER doctors in 2005 and only backed down under pressure from the union. ER doctors in New Mexico and New York have also gotten the same shoddy treatment. I don’t understand this mad rush to replace good ER doctors when there is a supposed shortage of ER physicians and a full 38% of ER physicians in this country are NOT ER residency trained and ABEM certified, approximately 13,000 physicians.
What I also find distressing is that no one is speaking up for my friends. Not the AMA, and ACEP, which is supposed to advocate for ALL ER doctors (not just the ER trained, ABEM certified) has been far from helpful, in spite of their policy which states:

“A qualified emergency physician is defined as one who possesses the training and experience in
emergency medicine sufficient to evaluate and initially manage and treat all patients who seek emergency care. ACEP believes that the ED medical director should be responsible for assessing and making recommendations to the hospital’s credentialing body related to the qualifications of emergency physicians with respect to the clinical privileges granted to them. Such qualifications may include

-professional credentials such as board certification;

-objective measurement of care provided;

-experience

-prior training;

-and evidence of continuing medical education.

Although board certification in emergency medicine is an excellent benchmark that should be considered when delineating clinical privileges,
no single criterion should provide the sole basis for decisions regarding an individual’s emergency medicine practice.” (Approved 1985; Revised 1991; Revised 1995; Reaffirmed 1999; Revised 2004)

Some organizations, such as the EMRA and the AAEM even actively campaign against their non-ER residency trained colleagues. Is this what we’ve come to? No wonder the malpractice lawyers and insurance companies have no problem picking us off. Instead of getting our act together and supporting one another, we are too busy stabbing each other in the back.

To the hospital staff’s credit, petitions were circulated, special meetings were held, and outraged letters to the administration and the press were written, there was much wailing and moaning, but to no avail. My friends are gone, and as one of the other doctors said, “The ER is a strange and cold place” without them. ER care since they left is more fragmented and confused, because the new guys are still on a learning curve and they don’t know the patients or the other docs.

All this has left those of us remaining disgusted and demoralized, but we will recover, and life will go on. Excuse me while I go throw up now.

Links:
“Qualifications” on Scalpel or Sword
“Rant” on Gruntdoc
Disposable Doctors 2: ER Docs Fight Back in NY
News from AAPS vs. NY-DOH

Suicide and the Single Female Doc

SUICIDE HIGH AMONG FEMALE DOCTORS
MORE THAN DOUBLE THE RATE OF GENERAL PUBLIC from the Harvard News Office

(What the %@#*! Do you mean that in addition to the ER docs not looking anything like George Clooney and neurosurgeons being far from “McDreamy”, I am now at 2.27 times increased risk of suicide compared to the general population? I need a drink.)

“Male doctors take their own lives at a higher rate than the general population of white men in the United States. That’s been known for some time. Now, the largest, latest study of physician suicides in this country has found that female doctors take their lives much more often.

The study was undertaken by Harvard Medical School researchers following the death of a young female physician who took her life in the School’s library.

Eva Schernhammer and Graham Colditz examined the results of 25 studies of physician suicides and concluded that male doctors killed themselves at a rate 41 percent higher than that of other men and women. The more startling finding was that female doctors take their lives at a rate more than twice (2.27 times) that of the general public.

“We do not yet have a clear answer to why this is,” admits Schernhammer, who works at Brigham and Women’s Hospital, a Harvard teaching affiliate in Boston. “There is evidence that depression, drug abuse, and alcoholism, possibly related to stress, are often associated with suicides of physicians. Female physicians in particular have been shown to have a higher frequency of alcoholism than women in the general population.”

The women may feel more stress because of gender bias and an increased need to succeed in this male-dominated profession. That seems likely, but Schernhammer says there have been no conclusive studies to back it up. She also notes that being single and not having children, which applies more to women than men in medicine, “has been linked to higher suicide rates.” (italics mine)

According to another study, done last year, the most common way that doctors take their lives is by poisoning themselves, often with drugs taken from their offices or laboratories.

Critical of themselves

The Harvard researchers published the results of their investigation in the December issue of the American Journal of Psychiatry. In this report, they cite evidence from other studies that doctors who kill themselves “are more critical of others and of themselves, and are more likely to blame themselves for their own illnesses.”

Other studies conclude that doctors feel uncomfortable turning to their colleagues for help. Instead, they may “resort to alcohol or drugs and isolation. Once they seek help, it appears likely they are not taken seriously enough by their fellow colleagues.” One investigation found that more than half of physicians who sought help later committed suicide. Although they had been diagnosed with psychiatric problems, none were hospitalized before they took their lives.”

Read the full article in the Harvard Gazette (Feb. 3,2005)

Shoot, I better get married and start popping out kids fast! Oops, too late, there goes my last viable ovum. It atrophied while I was attending an interminable dinner in honor of the retiring department head, or maybe while I was doing a consult in the ICU, or more likely while I was watching the “Law and Order” marathon last weekend.

I can blame no one but myself, since I used to have a predilection for my emotionally unavailable colleagues who like to wield scalpels (even when they’re psychiatrists), plus my answers to the Medical Student Compatibility Test, I admit, remain mostly A’s.

But I refuse to hide behind the “men are intimidated by intelligent women” myth. Rather, I’d say women are more tolerant than men of self-obsessed, narcissistic workaholics particularly if they have an “MD” after their name and make at least a six figure salary. A reasonably attractive, open, kind, and considerate person should be able to find a loving companion even if they’re more intelligent, as long as they don’t:

require that they be addressed as “Doctor” at all times (except in bed)

constantly remind people of their 4.00 GPA

constantly remind people that they “save lives”

Instead of blaming myself (which would make me self-critical and increase my risk for suicide), I blame the media. I blame “Dr. Quinn, Medicine Woman”, “General Hospital”, and “Gray’s Anatomy” for raising my expectations that my romantic life instead of withering away, would flower and bloom during residency/ practice, just waiting for the hunky mountain man/ surgeon/ cranky but brilliant diagnostician beyond the double swinging doors.

I don’t want to make too light of something that is a definite health concern for myself and others of my ilk. Depression, isolation, substance abuse are risks for anyone in a demanding and stressful profession and single people usually have less family resources to rely on when these problems arise. But they don’t have to. Someone who is deliberately single (“single by choice” as opposed to “single by accident”, see links below) can cultivate family, community, and friends. I have a group of other single female docs I go out with regularly, sort of “Sex and the City Hospital”. At this point in our lives, we certainly have less stress than other working women who are juggling full-time careers and raising families, but we have to learn to deal with other stuff as well.

And if you really want to revive the single female physician’s will to live, just restore Dr. Doug Ross to his rightful place in the ER.

“Living Single” Links:

JAMA Consensus Statement on Depression and Physician Suicide
The Secret Lives of Single Women
The New Single Woman

Burn-Out

It starts with a rumor, whispered in hushed tones among classmates and co-workers, as if  some misfortune had befallen or as a cautionary tale. “Did you hear about so-and-so? He/ she was in the prime of her career when BAM!, up and quits his/ her practice, moved out of town.  Couldn’t handle it. What a shame, what a waste.” And we all shake our heads, secretly wondering whether we might be next.

It happened to one of my best friends.  She was a superb physician, giving 200% to her cancer patients.  But the demands of family and career proved to be too much and she quit her practice and decided to stay home with her kids.  She is happy, and her family is happy.  But she has to continuously keep justifying her decision to friends, her parents, and colleagues.  It was the right decision for her, because this is what she had to do for her own sanity.  She would not have been of much use to her patients or her family if she persisted in a career that was making her miserable.  I do not believe her training and education were wasted because she helped many many people while she was practicing and the experience made her a wiser, better person and parent.  Furthermore, she had the courage, which most of us lack, to recognize and admit that she was miserable and to make a very painful change.

The medical culture does not encourage admitting to vulnerability or weakness, in fact in the lingo of residency training, trainees who do not perform up to standards are called “weak” and are stigmatized.  We are taught to “soldier on”, similar to the reports about war veterans with Post-Traumatic Stress Syndrome who feel ashamed for admitting that they have a problem and need help. 

In a study on medical career burn-out conducted by Vanderbilt University, it is characterized by “emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment”.

The study goes on to conclude that: 

“Preventing burnout-a responsibility of all physicians and of the healthcare organizations in which they work-entails the explicit promotion of physician well-being.  Physicians must be guided from the earliest years of training to cultivate methods of personal renewal, emotional self-awareness, connection with social support systems, and a sense of mastery and meaning in their work.  Maintaining these values is the work of a lifetime.  It is not incidental to medicine, but is at the core of the deepest values of the profession:  ‘First, do no harm.’ 

Harmlessness begins with oneself.  If physicians hope to heal the distresses of the 21st century and lead their patients to enjoy healthy, sustainable lives, they must show that this is possible by their own lives of sustainable service that emanates from the depths of spirits that are continuously renewed.”(italics mine)

So, whether you’re in medical school, residency, or in practice for years,  you have to take care of yourself before you can care for others. One thing we can change is to talk about it more openly without the stigmatization. As with all things, awareness and prevention are key.

So, here are some other useful links for dealing with/ preventing burn-out:

Emergiblog

BMJ Career Focus, “Will you burn out?”

MomMD, “Physicians giving it all up?”

Beginnings

It’s a new year, new blog.  Time to think about where I am and how I got here.  Lately, I’ve bumped into a few young people, hopeful and starry-eyed about a career in medicine, who ask me for advice.  I give them some encouraging words, because I do believe that medicine is a great and noble vocation.  But as they walk away, I can not help but gaze after them with compassion and a touch of melancholy.

Medicine was always a given for me. From a very early age, I knew I wanted to be a doctor.  I don’t think it was due to parental brainwashing, because my mother is a physician and she has not always been encouraging in my career goals.  I think it has something to do with personality, my interest in science, and my desire for control.  There is nothing as scary and humbling as the experience of serious physical or mental illness.  No matter how wealthy or powerful you are, you are vulnerable and at the mercy of others when you are ill.  Studying medicine gave me knowledge, which makes me feel less out of control.  You probably can’t do much about whatever’s happening, but you can at least understand it and maybe predict what may happen, which is comforting, in a way.  Studying the body is the first step in self- knowledge, and hopefully, self acceptance. 

So, why did I become a doctor?  Now, I realize because I had to.  And to everyone else who wants to become one, do it because you have to, and not for anything else.