Pamela Wible: We just got back from leading a physician retreat and this is actually my 16th physician retreat. Sydney, you’ve been co-facilitating these retreats with me for years and I just want to check in with you on something that I’ve noticed. I’m realizing more and more how many physicians are suffering with PTSD, even residents and medical students at the very earliest stages in their careers. Are you noticing that?
Sydney Ashland: Pamela I just got off the phone with a physician who specialized in emergency room medicine who is haunted by PTSD, survivor guilt, feels a total disconnect from the practice of medicine. I just find it so tragic that the very people who save hundreds and thousands of lives yearly are left as mere shells of the people they used to be. They’re no longer able to relax, feel joy. They’re stuck in this never-never land of misery and pain. It’s just so maddening to hear the same stories over and over when it feels so preventable. We just have so few medical professionals that are trying to serve so many people. I know that administrators feel crushed by the numbers, the health issues, the lack of consistent healthcare. They’re trying to stay competitive and profitable. I understand that.
Schools are trying to stay cutting edge, but no one is really coming up with those commonsensical answers, those interventions that can keep our medical warriors, our medical geniuses in the field. Instead, everyone shows up as victims. The hospitals, the medical schools blame high overhead. Insurance companies join in that refrain as well, and there’s a lack of innovative programs and strategies to address these needs. Everyone is passing the buck and the problems are not only exacerbated but they seem like they’re escalating. Is that your perception?
Pamela Wible: Yeah. I’m seeing more and more, and even younger people who are trying to flee their profession before they’ve even started practicing really, right?
Sydney Ashland: Yeah. I think part of that is that these medical schools are trying to prepare these students for the unbelievable pressures and stresses that they’re hearing about and know about in the medical field. Instead of really resourcing medical students and residents, it’s depleting them, it’s leaving them scarred and stressed and with post-traumatic stress disorder. Then they can’t practice medicine. They’re not going to survive post-residency. That’s what I find so, for lack of a better word, I’ll use it again, so tragic. It’s a tragedy.
Pamela Wible: I definitely want to go through some of the, maybe top five things that I’ve noticed that lead to PTSD in medical students, residents and physicians. There really is a lack of leadership in medicine. What’s ending up happening is you have the old guard just preparing people to do it the same way we’ve always done it because that’s how we’ve always done it. The world is not what it was 20, 30, 40 years ago. There are so many things that have changed in medicine. To have this knee-jerk reaction to lock medical students back into this regurgitation-memorization cycle when we can obviously access things at our fingertips. We need to have the joy of learning. We need to stop pushing people to continue in a system that’s obviously failing and imploding, right? We need new thinking. We need new ways of training physicians. We need to stop terrorizing them and violating their human rights.
Sydney Ashland: Exactly. We need leadership to do that. I feel a call to action for those in leadership positions right now to be brave, to find their courage and to begin to address these problems. For those that are in the rank and file who feel that conviction, that energy of activism within themselves to step forward as the new leaders, because that’s what it’s going to take in order to create the change that is necessary. I know that you and I, outside of the system, are trying to serve as leaders for those who feel like they need to leave the systems in order to not only live their dream but live their passion with attending to patients and serving their communities.
Pamela Wible: Right. I just want to add in there. I haven’t really left the system. I am practicing medicine in alignment with my highest values. I still take insurance. I submit my own claims. I practice like any other physician would practice, but I am autonomous in my own clinic. Obviously, I’m a truth seeker and a truth speaker and I’m not afraid to tell the truth. That has made me, to some people, a little bit fringy. As far as how I practice medicine, I’m very conservative in my own practice. And I love to encourage others, nurse practitioners, PAs, physicians, veterinarians, others in healthcare to really take the reigns back on their profession and practice an alignment with the highest values that brought you here.
Sydney Ashland: Excellent clarification. Excellent. That is exactly what I feel convicted to join you in doing.
Pamela Wible: Before we launch in, I don’t really have these in any particular order, but I thought we could address the top five things that we both feel lead to physician PTSD. One thing I’d like to preface this conversation with is that it’s so very important to tell the truth. I think many of us scurry around the truth using words that are absolutely inaccurate like burnout. That’s a word that I do not use because it’s a victim blaming and shaming term that does not address the true reason for people feeling so discouraged and so unable to keep up. I want us to dive into the truth here and to encourage others who are listening to this to also use accurate and precise terms for what is causing the suffering in your life. Because if we didn’t do that with patients, we’d misdiagnosed people all day long if we just dance around the periphery with a double speak and inappropriate terms, right?
Sydney Ashland: Exactly. Yes. Give me some truth.
Pamela Wible: Yeah, I’m going to just give an overview here of the five that I came up with and then we can dive into each one. The first one in no particular order. Actually, the way I did organize these is chronologically. The order in which a new student, a premed, first day of medical school coming in would experience these things that would lead to ultimately a life that’s very disturbing and fits the criteria of PTSD.
Number one is medical training. We have a fear-driven medical education model that teaches us by terror. I want to address that. Number two, human rights violations that include chronic sleep deprivation, hazing, bullying, lack of access to food, water, inability to see your family, take care of your own bodily functions. Number three, vicarious trauma. Of course, high risk specialties like emergency department and neonatology and such are going to feel more of this vicarious trauma. Number four, losing colleagues to suicide. I bet there are hardly any physicians out there who do not know of another physician who has died by suicide and you’ve probably not been able to properly grieve the death of that suicide. This is terrible. You’re going back to work every day feeling at risk yourself and I want to address that. Number five is just the chronic toxic workplace environments that we are in every day. Shoved in this assembly-line, big-box clinics, which are dangerous for our own health and the health of our patients.
The first one here, medical training, I thought I’d share two stories that came to me. There are letters that I’ve received. These are actually published in the Physician Suicide Letters—Answered book, which is available free as an audiobook if this would help you. Anyone out there, you’re welcome to download this. Number one, this is from a retired specialist in her 60s who wrote me:
“I was happy, secure and mostly unafraid until med school. I recall in vivid detail the first orientation day. Our anatomy professor stood before an auditorium filled with a 125 eager, nervous, idealistic would-be healers and said these words. ‘If you decide to commit suicide, do it right so you do not become a burden to society.’
He then described an anatomical detail how to commit suicide. I have often wondered how many auditoriums full of new students heard these words from him. I am sure someone stood in front of us and told us what a wonderful and rewarding profession we had chosen. I do not remember those words, but I do remember how to successfully commit suicide with a gun.
One month later on the eve of our first monthly round of six exams in one day, I had my first full-blown panic attack. I had no idea what was happening. I thought I was losing my mind. I took a leave of absence and made up excuses. I returned untreated with maladaptive compulsive behavior, completed med school and survived the public pimp sessions and all the rest.
No one ever suggested that the process was brutal or the responsibility frightening and no one offered us help. I have maintained contact with only one colleague from med school so I do not know how the others fared.”
I just want to say I have chills reading this like every time. This is teaching by terror. What do you feel? I’m going to read another letter in a bit, but I want to know what do you feel?
Sydney Ashland: Well, one of the things that stuck out to me was the fact that this person had no idea what was happening to them. In the midst of this full-blown panic attack, they felt like they were losing their mind. When we are in a terrorized situation, and you talked about medical training as fear-driven and teaching by terror, we lose our ability to respond and we enter a place of high reactivity so that we are reacting to. That’s the whole panic attack.
She was having this huge reaction rather than being able to respond in the situation. We call our paramedics and firemen—first responders. We don’t call them first reactors. I don’t want somebody working on me who is in a reactive state because they are going to be so infused with adrenaline and stress hormones that they’re going to be in a high state of reactivity and not necessarily responding in a way that is thoughtful, that allows for pause, that helps them respond from a decisive place rather than reacting from a triggered place. That’s what stood out to me in that first story.
Pamela Wible: It just makes me wonder. She’s retired now, but gosh, how did she practice medicine? Did she carry this with her when treating patients? Was she still impacted by this?
Sydney Ashland: I’m certain she did. Absolutely. As we go through all the labels that you have identified as a part of the PTSD cycle in the medical field, we will, I’m sure, touch on other areas that she experienced, because you know she experienced human rights violations. You know that she experienced some vicarious trauma and then what are the characteristics when we are in those states.
Pamela Wible: Right. The next one I want to share is from a surgery resident. Again, that would be a high-risk specialty of witnessing all sorts of trauma. What I noticed when reading this, it brings up the fact that our attendings have been mistreated themselves during training. They don’t even have the teaching skills that they often need to handle these high-stress environments and teach in a compassionate way. I mean there’s multiple victims here, right?
Sydney Ashland: Absolutely.
Pamela Wible: Lisa, a surgery resident in New York writes me,
“I began my residency in California and during that time was very depressed, abused within my training program. My depression impacted my performance and I was eventually fired. I was lucky enough to find another position and continue my training, however, some days I feel my depression and despair returning primarily when I feel my career has been irreparably damaged by my departure from my first residency program.
Those feelings were initially tied to hazing and bullying that are an integral part of the educational program there. Sometimes, I can still hear those attendings in my head saying things like, ‘Watching you operate is like watching a retarded monkey.’ Or, ‘Do they ever teach anatomy at your medical school? Our students know more than you.’
It’s paralyzing. I am reaching out to you for two reasons. I’m interested in eradicating the abuse in medical education. I’d like to have a career in academics and to influence policy regarding the treatment of trainees. More importantly, can you help me make the flashbacks stop? Can you help me not worry so much about my future? Can you help me with my depression related to my change in career trajectory? Thank you for your work.”
I think when I first received this and I saw the flashback word was when I first realized this is PTSD.
Sydney Ashland: Full-blown PTSD. There’s an excellent book that Peter Levine has written about Waking the Tiger. He is an individual who worked at Walter Reed hospital for years with vets who have PTSD. One of the things I would encourage this woman and anyone listening is that in reading that book, you will be given some exercises that help you with the flashbacks. Where you can enter that place in your trauma and tell your brain a different story.
You have to be in a thoughtful place. You should be in therapy or have at least a supportive network to help you during this phase of healing, but the flashbacks can stop. You can move from reactivity to a responsive and thoughtful life. You can return to taking care of yourself and not continuing the abuse cycle, because so often people like Lisa leave their surgery residency, depriving themselves, treating themselves poorly, having circuitous and habituated thought patterns that are intrusive. So that even when they’re successful, what they are haunted by is that classmates taunting the time they made a mistake, that depression that ended up in them leaving medical training even though they continued somewhere else. It can be helped. There are interventions.