To begin, three stories from my residency.
Story 1: I did a good part of my residency at a public hospital in St. Louis. The hospital was in what was then called "a bad part of town," with all that implied: an economically depressed and crime-ridden inner-city disaster area. The parking lot for house staff was a block away from the main entrance, and women house officers were escorted to their cars by hospital security guards at night. If your car was parked on the street, you might come back to find the windows shot out and the stereo system gone.
Inside, the hospital life was scarcely better. Like many inner-city hospitals, it was an old, decrepit place that was inadequately staffed and the antonym of "modern." The wards were large, open spaces with maybe 20 beds per room. If you needed to see a patient in the middle of the night, you turned on the lights for the entire room or brought a flashlight. The lab seemed a mile away from the ward, and medical students got their exercise running STAT labs. You did not give the blood work to the underpaid runners employed by the hospital, for if you did the lab work was unlikely to be processed. Once, or so hospital legend had it, the old elevator broke down, unable to reach the first floor. Underneath was found years-worth of shattered red- and purple-top tubes, tossed there by the hospital runners.
These were the days before modern hour limitations for house staff, and sleep was essentially impossible when on call, and you were on call every third night. Several of my colleagues fell asleep while driving home after being awake for 36 hours. There were no limitations on patient numbers: the idea of capping a team's census would have been met with incredulity. Early in one's training, before you got used to being repeatedly abused by the training process, the stress could be almost unbearable.
A member of my intern class, one day early in his training, said to his team, "I need to go move my car." You did this if you had parked your car on the street when the staff lot was full; once the night shift, left you moved it to safety. Hours passed, and someone finally noticed that he had never come back. Had something happened to him?
We eventually learned that he had gotten in his car and started driving. He had just meant to drive to the staff lot, but the next thing he knew his car was entering Kansas City, far across the state of Missouri. Of note, prior to starting his internship, this New Jersey native had never been west of the Mississippi River. "I need to go move my car" subsequently became my intern group's catch phrase whenever things got out of hand on the wards, our signal to senior staff that they needed to back off.
Story 2: One night, I was manning the ER at our county hospital. A "patient" was brought in by an ambulance crew. He was quite dead, but you were not legally dead until a doctor said you were dead, so they had carried him in from a local hotel for me to make it legit.
He was a psychiatrist from-you guessed it-Kansas City. He had driven across Missouri to Saint Louis, checked into the hotel, put out the "do not disturb" sign and then ingested a deadly cocktail of barbiturates, benzodiazepines, and narcotics. He didn't leave a suicide note, just empty bottles of pills. Hotel staff found him the following day, after check-out time.
Story 3: I was chief resident at the same program's VA hospital. The Medicine program ran the emergency room, and every third day one of the teams would staff the ER. In addition, there was a former medicine resident-let's call him John-who served as a permanent ER staff doctor. John had gotten into trouble during his residency, becoming addicted to morphine, and his license had been suspended. When his suspension was over, the chief of medicine had, in hopes of giving him a second chance, hired him to work the ER. This was in the days before being an ER doctor was a specialty, so a very long time ago.
My wife, an RN, also worked the ER. She told me of nursing staff suspicions regarding this doctor, of his tendency to overuse topical cocaine for patients with nosebleeds. They couldn't prove anything, but they thought he might be diverting the drug for personal use. No one did anything, me included. We thought we were giving him the benefit of the doubt.
One day, I was sitting in the chief resident's office on the sixth floor when a code blue was called for the ER. John had been discovered in a bathroom adjacent to the ER in cardio-respiratory arrest. I ran down six flights of stairs to the first floor ER, along with several other colleagues, and got there just in time to see him pronounced dead. He had overdosed on morphine. The syringe was lying by his body.
The strange thing was that I had just seen him an hour before while walking through the ER. He had pulled me aside and asked me to look at a lesion on his scalp: did I think it was anything to worry about? I looked at it-benign-told him not to worry and moved on. I had sensed no desperation or depression, even through the retrospectoscope. The coroner ruled it a suicide. I always thought it was maybe just an addict's mistake, but who knows? Addicts make lethal mistakes all the time, and they can be hard to separate from suicide.
I was thinking about these memories recently, encompassing as they did burnout, suicide, and addiction while speaking to colleagues about the stress physicians face. We all had similar stories. And we all had stories more recent than our training. We all knew or had heard of a colleague who had committed suicide or left the profession in despair or took illicit drugs. And these, of course, are only a few of the many ways a doctor can go off the rails.
Consider these numbers: the suicide rate in the general population is 12.3 per 100,000 person-years. Among cancer patients, the suicide rate is 28.58 per 100,000 person-years. The suicide rate among physicians is somewhere in the 28-40 per 100,000 person-years range, higher than any other common profession. Think about it: a cancer patient's doctor is at at equal or greater risk for committing suicide than the patient. It reminds you of those stories you read where someone is drowning, and a passerby dives in to save them and ends up drowning as well.
This is a global phenomenon, not just the experience of EHR-abused American physicians. Doctors are often stressed, depressed, alcoholic, or substance abusers with access to the means to end their lives.
Doctoring is a high-stress profession, made more so by our inability to ask for help. That doctor I pronounced dead as a resident: where does a suicidal psychiatrist go, and what does it say that someone whose job it was to provide help was incapable of finding any? Maybe something about that individual, but I suspect it speaks more to the profession, about the stigma of being considered psychologically weak in a job that requires one to pretend that weakness does not exist and cannot be tolerated.
Sir William Osler wrote his famous "Aequanimitas" essay in 1889, and it has remained a touchstone of the medical profession ever since. Originally delivered to the graduating medical school class at the University of Pennsylvania, it was profoundly influential for generations of physicians entering their careers. It was handed out at medical school graduations around the country. I was given the 1932 third edition as a gift, and it is one I cherish. Osler was a brilliant stylist, erudite in a late-19th century way, and still a joy to read even if dated in his conclusions.
Whatever was going on behind the mask, Osler said, we owed it to our patients to project the quality of imperturbability, which he defined as "coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgement in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm."
This quality of imperturbability was not just for your patients, said Osler, for "there is a struggle with defeat which some of you will have to bear, and it will be well for you in that day to have cultivated a cheerful equanimity." Osler was not a medical oncologist. Cancer doctors "struggle with defeats they have to bear" every single day. They must if they are to remain in their profession. But cheerful equanimity in the face of regular goals of care conversations, sandwiched between harried attempts to complete your latest EHR entry, while your nurse practitioner tells you that you are falling behind and better get moving? Equanimity maybe, but cheerful, not so much.
Is this mask of imperturbability-and it is a mask for most of us, even if it eventually fastens to our faces-actually a good thing? Certainly, patients prefer their doctors calm and confident. But it is, I think, too much to ask of any human being for a sustained time. Osler might have been describing a lieutenant leading a platoon into battle, but even soldiers do not fight every day forever, and if they do, they soon experience battle fatigue and subsequent post-traumatic stress. You see that in the stories coming out of hospitals in New York and Milan during the coronavirus pandemic, where ER doctors, ICU physicians, and ward nurses reach a point where the only way they can drag themselves to work in the morning is to rely on whatever remaining shreds of professionalism keeps them going-going for just another day in the face of exhaustion and fear. And at some point, they can just stop caring, or care too much to continue.
The long-term survivors are those who gauge their own energy, find ways to recharge their batteries, let off steam-choose your own cliche-and always bear in mind that if you are in it for the long haul you need to take care of your own mental health even as you take care of others' physical health. We need to do better at ensuring that this wellness toolkit is there from the beginning of training. And then, perhaps, we can put on Osler's mask.
Anyways, that's what I think. I need to go move my car.