The Dark Side of Doctoring

Episode 1. I’m a surgeon. I’d like to think that I’m resilient and well adjusted, having gone through medical school and rigorous surgical training. I’ve been a doctor for 13 years and much of that period has been spent training to be as good a surgeon as I could ever be. I have great family support, a physician wife who understands my work and I’ve never been diagnosed with a mental illness.

The suicide death of Dr Andrew Bryant, a Brisbane gastroenterologist last week hit a raw nerve. His wife wrote this honest and courageous letter.


Although I’ve never had serious suicidal thoughts, I – like many other doctors – have been through many dark seasons. Depression, anxiety, burnout, suicidality, hopelessness, lethargy, anhedonia, feeling flat, worry, and the like are all different flavours of the same phenomena: the negative human response to internal or external stressors. Of course, the causes are always multifactorial. It cannot and should not be oversimplified to family history, genetics, behavioural deficiencies, bad environment or poor social support.

When I carefully dissect my dark seasons, some common themes often emerge. Work is often the critical exacerbating and perpetuating factor in those dark times. Because as a surgeon I spend the vast majority of my lifetime at work, what happens there influences all other aspects of my life including my marriage, family and social life.

Here are 3 common things that have thrown me into some dark pit of despair:

1. Loss of Control

I have lost control of my days. I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off. When I was preparing for surgical exams, I’d be working and studying from 6.30am to 10pm everyday, seeing my family only on the weekends for lunch. I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car. I used to have my sleeping bag, toiletries and change in the boot of my car because I didn’t know if I was going to make it home some nights. Plans change every single day at work because of emergencies. I can’t even be sure what the next hour will bring when I am on call. You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call. The intensity and personal damage of these on call periods are often forgotten.

Not only that, we are losing control of health care in general. Everyday, there’s a new form, a new guideline, a new protocol, a new health software, a new policy all dictating, restricting and modifying clinician activities. Some of these policies are written by people who do not see patients. There’s a whole paid industry dedicated to restructuring what doctors and nurses do to reduce costs and increase output.

2. Loss of Support.

Just imagine. I start my days at 6am. I wake up to an email alerting me of the number of discharge summaries that haven’t been completed and the various computer based modules I have to complete (hand washing, privacy, lifting patients, etc). Round starts at 7am. I see 15-20 patients with various travel forms, certificates, scripts that need completing. All to be done via the electronic health system, clunky, not user friendly, takes a long time to log in. Then I start an overbooked operating list at 8am. There are 7 cases booked. I have no say on who gets on the operating list and the order of patients. The first patient haven’t been checked in. The diabetic one is hypoglycaemic. The infant is cranky. The autistic child is running away. The interpreter is not here yet. The computer is still not logging in. The password is expired. I used to be able to arrange the operating list because I know that some operations take longer than others. But now, the bookings office determine that that all my tonsillectomies take 14 minutes because that’s the average time recorded on the computer. The moment I scrub in, the timer starts. The moment I unscrub timer stops. Click. Click. Click. Because the theatre bookings does not take into account the interpreter time, pre-med period or transfer to ICU, the list is running late. The nurse in charge is breathing down my neck to finish on time. I still took about 14 minutes on each case, but the team is delayed by external clinical reasons. The theatre team is anxious to finish, everything is rushed, and mistakes are bound to occur.

In the mean time, I field 12 phone calls from ED, GP and other units. By now there are 3 patients waiting for me in ED and 1 being flown in from another hospital. The operating list is finished late. I rushed to ED, and gulped down a cup of instant coffee. Then I arrive late to the afternoon clinic, which again is overbooked. Clinic nurses are not happy. I see 8-10 patients while taking more calls. I try to discuss complex surgeries with patients but I keep getting interrupted by calls and paperwork. Then I run back to theatre for an emergency case. By this time I’m set up for failure. I’m tired, cranky and my head is full of jobs to do. I do the afternoon round, see more consults, admit more patients and dictate letters. I have taken up to 70 calls on a 24h on call period. By 6pm I’m totally exhausted. I grab a packet of chips, ginger beer, and start working on the papers I was meant to write up. I review the case notes for the next couple of days. I get home between 7-8pm. Grab dinner and put the kids to bed. I get called back in and I take a patient to theatre for an emergency procedure. I come back just after midnight and sleep. I get called four more times between midnight and 6am.

6am. Repeat.

I have lost control of my days and I have lost support. When can I actually find support? I don’t have time to talk to my colleagues about life. I don’t have time with my family. I don’t have time to catch up with friends. Social ties are lost when one stepped into medical school. I’ve lost count of the number of significant life events I have missed (birthdays, anniversaries, reunions, school recitals, first walks, etc.)

I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital.

I know where I can get support, but practically, when and how am I going to get that support?

In addition, doctors who scream for help may be formally reported, therefore having restrictions placed on their practice and then incurring higher medical indemnity fees in some situations. Trainees who ask for help may be labelled as underperforming and have to be commenced on probation or remediation. We may not have practical access to the support that are often advertised.

3. Loss of Meaning

Interestingly, the above physical and emotional stressors are reasonably manageable to me. I’m understanding my own physical and emotional limits. These stressors induce  exhaustion, but the excitement of the work and the intellectual challenge of the job bring a lot of personal satisfaction. I do get emotionally shaken at times because I deal with dying cancer patients, emergency airway disasters and sick complex children, but I get by.

I am realising more and more that what brings me greatest distress is the relentless administrative pressure which take away the meaningful clinical engagement I have with my patients. And I wonder if this is what many young doctors are experiencing as well. Medicine used to be a meaningful pursuit. Now it has become a tiresome industry. The joy, purpose and meaning of medicine has been codified, sterilised, protocolised, industrialised and regimented. Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators.

I have little say in organising my very own operating lists or clinics. Even the power to re-order the operating list has been taken from the surgeon. The thing that I love doing (operating & seeing patients) is being measured, recorded and benchmarked. The clinics are overbooked to get numbers through. The paperwork for each patient encounter is increasing with each passing year. There are so many other non-clinical departments dictating what I should do and how best to do it. The mantra is “cost-effectiveness and increased productivity.”

I went into medicine knowing that I will have to sacrifice much for the sake of my patients. What I am realising is that today in modern medicine, a doctor is just one of the many commodities in this complex industry. It’s no longer about the patient. It’s about the business of hospitals. Patient satisfaction officers, Theatre Utilisation officers, Patient Flow Coordinators. These are all business roles.

As a surgeon I spent a year in a hospital where I smiled on the way to work and I am so grateful for my job. I looked forward to long days because I knew what I was doing was significant. Another year in another hospital, I dreaded going to work. I hated being on call. I was burned out and I couldn’t control my emotions at work and at home. I’m not inherently an offensive or rude person, I’m just a person pushed to the limits and set to fail because of the circumstances around my work. Same surgeon, different jobs. The forces that pushed me to losing control of my emotions are likely the same forces that might push some of us to suicide.

To some hospitals and their business, I’m not a Surgeon. I’m just an employee. Overworked, burned out, replaceable. The noble call to Medicine has been suffocated by the bureaucratic force exerting itself as the medical industry.

This is Episode 1 of a Trilogy.

Episode 2: The Dark Side Awakens

Episode 3: Restoring Hope and Humanity to Health Care. Here I write about the 3 corresponding antidotes to the 3 issues above. 

Would you agree or disagree with my thoughts? What other “Dark Side of Doctoring” issues can you think of?


217 thoughts on “The Dark Side of Doctoring

  1. Franklin Warsh

    The same thing is happening everywhere (I’m Canadian). The steady creep of bureaucratic micromanagement, the obsession with efficiency and cost-containment, the increased administrative load, the pain in the rear of EMRs, consumerism, dumbing down of medicine with guidelines…while there almost certainly never was a “golden age” in medicine, it’s become measurably worse in the last five or six years. My own experiences echo yours: http://drwarsh.blogspot.ca/p/important-link.html, and I still have anxiety around seeing patients.

    Get some rest, get the help you need, and make whatever changes you need to keep going. You aren’t replaceable, full stop.

    1. DrEricLevi

      Thank you Dr Warsh.

  2. annemalatt

    Hey Eric, this is a great blog. Thank you so much for taking the time to write it. You say it as it is for so many of us. We don’t complain much, we just keep going until we cannot, as the suicide of this great doctor has highlighted. Until we start caring for ourselves in what is now a health system which is devoid of the care that used to be part of health care, such tragedies are going to keep happening. We can no longer just keep taking it…the change starts with us.

    1. DrEricLevi

      Thanks doc.

    2. Kim Clinen

      I need to finish reading this. This is so important! I’m worried health is being overtaken by time bandits who’s purpose is to crunch numbers and forget the human face of health. Our patients and more importantly ourselves.

    3. Nate Sharon

      While I agree the change should start with us, many organizations blame the physician for the poor health and stress they are going through. As though it’s our fault for being overworked and also for not being able to “self care” it all away. If it didn’t take me one day literally to physically recover from the hell week, then another day to attend to my family and adult responsibilities, maybe I would be off doing yoga and self care. But I’m worked too hard to even lift my head at night and get some groceries, let alone go do some self care. We need to organize and form unions. Enough!

  3. Archie Lamb

    Bravo I could not agree more! Surgery is very stressful and work load affects contemptment and family life however we soldier on hoping we are appreciated for what we give! Fortunately your wife is medical and understands. My ex wife did not understand! Archie Lamb FRACS FRANZCO

    1. DrEricLevi

      Thank you Dr Lamb.

  4. Jennifer

    Beautifully written. I’m not a surgeon but the pressures to see more patients in less time is still applicable. And then, now that they are herded through like cattle, our “success” is linked to their evaluations of overall “satisfaction.” And due to customer service mentality, families are more demanding, unappreciative, and entitled.

    Hopefully this recent event is a wake-up call for hosp admin. But more importantly, an opportunity for self-reflection, and permission to reach out for help. Put your oxygen mask on first.

    1. DrEricLevi

      Thank you Jennifer.

  5. Sherman Kwan (@sherm_k)

    Dear Eric,

    Thank you for sharing your insights. As a final year med student, I am looking forward to a future in what I still consider a rewarding vocation, albeit one being eroded by oftentimes nonsensical administration. From my observations, I also see some loss of the camaraderie amongst all the staff involved in the day’s duties. I hope this event will be a catalyst for more others to share and speak up. Maybe then will there be discourse that leads to proper understanding of the myriad factors as you mention. While admin is likely not going anywhere, I can at least hope for better cohesion amongst my fellows at the coal face of what can sometimes become an inferno of humanity.

    I was wondering, what would be three things you would thing could be changed now. Something small that would not require 40 meetings 3 audits and an independent review to inform a committee to possibly enact (hopefully anyway). Not necessarily paradigm shifting, but something small, simple and swift.

    Pebbles can upset boulders.

    Thank you.

    1. DrEricLevi

      Thank you, Sherman. I have thought long and hard about that “something small”. If you look back at my earlier posts, I wrote a series on 30 days to better doctoring. You can start there. The problem is that it is very hard to do on your own persistently in reality. The system beats you up. But if we all did these things together, maybe things might change.

      1. Sherman Kwan (@sherm_k)

        Thank you 🙂

  6. hsianloon

    The aura of invincibility

    Who would dare to share the fact that they are under stress or feeling depressed? The ideal doctor is meant to have a ‘ no problem leave it with me’ attitude, and never admit that they need help. After all , if you’re fighting for a specialist training posts, and there are two candidates with equally good CVs, word will have already gone around to the panels that that trainee could be ‘problematic’ because of their history of “extended leave with illness, family problems etc’ .
    Medicine is a small community, and gossip is everywhere

    My partner had tore her ACL awhile back and spent almost 3 months before she could actually walk and run properly without significant pain (to met calls). First week, people were sympathetic and offers to cover some calls. Second week, they started asking for her plans in advance as they wanted to plan their leave. Third week, they started saying she could do calls while sitting down and let someone else hold the met pager, and why she was being paid sick leave. that they asked why she can’t just sit in clinics the whole time and it was difficult finding locums to cover her. I picked up whatever calls for her that I could and allowed to.

    She was even being shamed at morning handovers for not being able to put up with the pain to work. Consultants would roll their eyes and scoff at how she wasn’t in ICU, so it meant she should be working.

    After that experience, I learned that medicine is not a place you can share any signs of weakness. Sure we are doctors to our patients, but we are animals to our own colleagues.

  7. Mohsen Hassani

    Great reflection and discovery Eric.
    I as a GP can reflect it to my role too and yet to be called ‘you greedy doctors ‘

    1. DrEricLevi

      Thank you Dr Hassani. As I understand, your struggles at the GP coalface is even tougher. Thank you for what you do for your patients.

  8. weis9790

    Agree with everything you said. We are not unfeeling automatons. We are not invincible Gods. We all have a breaking point. Mine came when a hired gun lied on the stand and misled a jury to rule against me. Now, I struggle to get out of bed every morning and regret ever becoming a doctor.

    1. DrEricLevi

      I’m sorry to hear. I wish you well.

  9. Jim Hill

    Very familiar with this scenario. As a rural GP proceduralist it is routine that city based administrators decide what treatments and procedures can be offered in a rural setting. In a rural hospital administration rules end the provision of procedures which were previously offered in a safe and efficient way, in some cases ,for years. The patients are no longer the focus of health care, rather the rather laughable goal of saving the minister from embarrassment, a thing they are quite incapable of doing unaided.

    1. DrEricLevi

      Thank you Dr Hill.

  10. Phoebe

    Excellent post- thrilled to see this disseminating the medical world on social media. So eloquently written- well done.

    1. DrEricLevi

      Thank you, Phoebe.

  11. Sarah Hosking

    Dr Levi – Did you teach Monash medical students ohh about 2008, 2009? I think you might have taught me anatomy, you were very good and always seemed to care about us students! In some ways I am the same as I was then – interested, curious and I like to think empathetic. However I feel like the constant barrage of both difficult/sad patients and also difficult work circumstances puts walls around my soul, I am constantly trying to lower! Thanks for the insight and I hope you get one of those jobs that puts a smile on your face soon 🙂

    1. DrEricLevi

      Yes, I did Sarah. I was an anatomy tutor and PCL tutor around that time. Thanks for dropping a line.

  12. Lawson Ung

    I am a resident at a major metropolitan hospital in Sydney, which also happens to be home to Australia’s busiest emergency department and also a major trauma centre. Can I please say thank you very much, Dr Levi for articulating some of the stresses doctors face on a daily basis when working for a system that has been set up to fail them? This year, I have lost two colleagues to suicide – and there is seldom a day when I do not think about them and the circumstances that drove them to take their own lives. The despair they must have felt – and frighteningly, that many others probably continue to feel feel. One in particular was a good friend to me, and it hurts me to think about the loneliness and hopelessness he must have felt…

    On top of working 60-80 hour weeks, the overtime of which is unpaid, I spend my weekends catching up with the study and assessments for my post-graduate studies and completing research projects which have become necessary to apply for specialty training jobs in the future. I come home to a younger sister – she’s only 11 – to find that I had completely forgotten about my promise earlier in the day to take her shopping, or to the movies – to find her asleep and that she probably won’t see me that week. I took my grandmother and parents out for Mother’s Day yesterday, and all I could think about the guilt in my heart because all of a sudden, nan had an antalgic gait from an atypical femoral fracture (how had I not noticed?) and how she’d be pushing on 80 soon, how I’d gone from seeing her almost every day to never at all.

    I’m relieved to find that I’m not the only one who feels utterly burned out. Some days I feel like I am doing something good, but most of the time it’s just about surviving. Thank you for this post – it made me feel like I am not alone.

    1. DrEricLevi

      Thanks Lawson. I’m sad to hear of your colleagues death. I fully understand the despair many of us doctors feel at the current state. I hope bringing up these issues will lead to a change in practice.

  13. Mel Ford

    So true. I have to be very careful about how much work I do otherwise I start to get very dark ( have still done my share of 20 hour days). I have learnt the hard way that if I am broken then I can’t help anyone. I find it difficult with my non medical friends and family that just don’t get it. They don’t see that doctor part time is normal person full time and that I work very very hard for every penny I get. I find it hard that I’ve busted my ass to do a really good job for a very complex patient but all admin sees is that I’m too slow. Take a deep breath. I do what I do because it means something for the person I do it for, the patient, the trainee, the team that cares

    1. DrEricLevi

      Thank you Mel. I agree.

  14. Vicky

    Hi Eric, thanks for your honesty in this article. It’s a seriously tough gig you’ve got going on. As a former doctor and now counsellor/therapist to doctors this does raise some concerns for me. For doctors who may be under similar amounts of pressure at present but who are desperate for relief or escape I fear that your experience may be seen as a standard to compare themselves negatively against, triggering thoughts of “this guy can cope with this why can’t I?” Particularly so in a culture where perfectionism is almost a condition of entry to med school and being committed to the point of exhaustion is seen as a badge of honour.

    The system will keep pushing doctors to perform in more and more intolerable conditions as long doctors are prepared to take it on. It relies on committed and dedicated doctors like yourself believing that self sacrifice is the only worthy way to a successful and worthwhile career. Cultural change needs to happen and that will start by raised awareness, and grass roots push back.

    I’d be interested to hear your thoughts. Please look after yourself.

    1. DrEricLevi

      Thanks Vicky. All I could do at this moment is share my thoughts and see if anyone else feel the same. Once we agree that there is a problem, hopefully we can collectively do something about it. I certainly was not planning to set myself as a standard. If anything it’s more of a plea for help. Thanks again.

      1. Vicky

        And a big thank you to you for sharing your thoughts so articulately. You mention “I know where I can get support, but practically, when and how am I going to get that support?” Is there anything that can be done to facilitate that? Would skype or email based support services be of help? It’s also worth noting that counsellors are exempt from AHPRA mandatory reporting requirements!

  15. Brooke Vickerman

    Eric, this is a great piece of writing. I hope as a collective group of colleagues in our busy hospital we can make life a little bit easier as we all ‘get it’.

    1. DrEricLevi

      Thanks Brooke.

  16. Micaela Abbott

    4 months ago, I lost my own sister Dr Chloe Abbott to suicide. She was a junior doctor, with a brilliant mind and so much to offer this world. I read your article and found myself just nodding the entire time, to everything you were saying. My family have spent the last 4 months actively advocating for changes within the profession. Something has to change or we will continue to lose these amazing doctors to suicide, because the currently system is so inherently flawed that it has made these doctors feel as though anything they ever do will never be good enough. My heart breaks every time I read or hear of another doctor suicide.

    1. DrEricLevi

      Micaela. Thank you. I have read of the brave story of your sister Chloe. I have had some private conversations with your other sister. You have been amazing as a family. I applaud your efforts in this arena. We can turn the tide. Thank you for all that you do.

  17. Anna Hau

    So well written Eric!! Saw this shared quite a few times on my fb feed and didn’t realize you had a blog! Your article had so many thoughts I’ve been harbouring for the past few years, written in such an eloquent way. Will keep following and thank you for being such a great colleague last year at lcch!! Hope all is well with you and your family!!

    1. DrEricLevi

      Thanks Anna. I wish you well. You’ve got my number. Call if you need anything.

  18. Catrina

    Thanks for your article. I do love my job (physician trainee) immensely, but to put things into perspective I have a 3 month old baby and and completing a masters degree at the moment. I keep being told that I must be exhausted, in this newborn period where “just surviving” is the goal. However, I am much, much less tired than I was at work. Also, I get to see family and friends again, sit on the couch and watch some TV while feeding my baby etc. this means I have had a much much greater quality of life at this time. It does scare me, realising the intensity of my job is much harder than caring for a newborn baby 24/7.

    1. DrEricLevi

      Thanks Catrina. All the best with the little one. Tough times but rewarding as well.

  19. Pushpa

    Hi Eric,
    Thanks for your well written article which outline pressing issues we all face these days. I do not see how things can get better for us. There are increasingly unrealistic expectations from doctors with limited resources. I used to have much greater satisfaction when working in my home country before I migrated here for a number of reasons. Some of the main reasons why working conditions are better for doctors in my home country are, there no bureaucracy related issues that matter to doctors, they are in control of what they are doing at work, it is easier to get support they need and the society /general public appreciate their work.

    1. DrEricLevi

      I understand, Pushpa. I hope we can slowly turn this thing around. Its not about the administrators or doctors. It’s about the patient. If we shift our focus there, we will regain the meaning of our work. I hope.

  20. Manali Jain

    Hi Eric,
    Thanks for your words – I think in general the life of a surgical trainee is much worse. My career as a physician and now cardiology training has been highly rewarding, but I can’t forget those days of twelve day stretches for many years and the nights with very little rmo cover. I’m one of the lucky ones because i have an incredible support network which includes a non medical husband who keeps me grounded. I still feel exhausted on my twelve day stretches. I agree with you that the roster and the clinicians we work with have a huge impact on our happiness in our job. There are many ways we can improve the current system, unfortunetly lot of it had to do with economic resource as well – hence the demands and over booked theatre and clinic lists. Still I think our generation genuinely wants to change things for the better. I think despite our pre decessors working longer hours, there was less patient workload, higher doctorly respect, less pressures of getting employment because of a saturated field and less medico legal implications. All these things have vastly changed the dynamics and culture of medicine over the years, and we need to implement changes to go with it.

    1. DrEricLevi

      Totally agree with you Manali. Thanks.

  21. Caren Zh.

    Hi Eric. I stumbled across your blog. You’ve put to words what many of us cannot even begin to explain. The loneliness and isolation during on call / nights / long shifts is real. None of our non-medical friends have event he faintest idea of how things are in the industry. Despite the sacrifices, I still love the job (Anaesthetics) and would choose it again without a second thought. Thank you for bringing awareness to the ongoing struggles we go through.

    1. DrEricLevi

      Thanks Caren.

  22. Chris Daley

    Hi Eric,
    This is a wonderful insight into life as a surgeon. I started medical school thinking I wanted to be an orthopaedic surgeon, so it is interesting I became a respiratory physician (pulmonologist). I chose this path because the respiratory physicians I encountered in my training seemed for the most part happy. I feel in general I have a lot of control over how I practice medicine and how I structure patient reviews and procedures, yet even so I often feel a little of what you so elequently describe here. I do see a lot of people under so much pressure in their work as a doctor and part of my role is trying to reduce these pressures and make medicine a once again rewarding career and something people can take pride in, without feeling that there is neverending pressure upon them. Keep up the fantastic writing!

    1. DrEricLevi

      Thanks Dr Daley. We need more people like you to value-add to our medical workplaces.

  23. Michelle G

    Thank you very much for your blog. You described the pressures of our job as surgeons so very well. I agree totally with the feeling of loss of control with surgery lists. If you are fast, they reward you by cramming your lists until it almost feels intolerable and you are always worried that you will make a slip from tiredness. If you are slow with one case then you always feel pressured to go faster to catch up so you don’t have to cancel anyone. And I agree with the thought that there is no one else to pick up the pieces if you dare to call in sick, especially at the clinic. Work just becomes incredibly hectic for the next few clinics as the patients get fitted in and you’re double booked the whole day.

    I’m thankful that I don’t work full time, and have a couple of days a week to unwind. Otherwise I’m sure that my health and my family’s health would not fare well.

    1. DrEricLevi

      Thanks Michelle. I’m sure you understand.

  24. Chloe Butler

    Eric, thank you for writing such an eloquent piece. It perfectly describes the struggles and frustrations common to so many of us in medicine, and I applaud you for your candour.
    I am very fortunate to work in a department (anaesthetics) that takes trainee and staff welfare very seriously, and in large part I think this is due to a shift in culture that has been actively pushed by our college over the past few years. I sense that this is not necessarily the case for my colleagues across the drapes, and I often find myself completely aghast at the crazy amounts of call you guys are expected to do in addition to your normal days.
    I have such respect for those who undertake surgical training, and while sometimes we may not always see eye to eye, I’m certain that there is more we can do to support each other.
    Keep up the good work!

    1. DrEricLevi

      Thank you Chloe. I think the new generation of doctors are tired of tribalism within medicine. I’m sure we’re all keen to do this thing together whichever side of the drape we’re on.

  25. Adam Coulson

    Great piece Eric. I think it’s time for senior doctors like myself to push back against a healthcare system that places these unreasonable demands on its medical staff. Thanks for speaking out.

    1. DrEricLevi

      Thank you Dr Coulson. Thank you for what you do for your patients and your trainees.

  26. Francesca

    Nothing inspirational to say, more that its a little comforting to see similar rosters and pressures elsewhere. I am a medical registrar and my time spent doing this job has a lot of the time felt out of my control. People do not realise how utterly destroying on call work can be. One week I was woken up 4 times every night and then did 12 hour days at work plus studying. The feeling of utter worthlessness such a week can bring out is difficult to describe but it is a dangerous beast we need to be aware of.

    1. DrEricLevi

      Stay strong Francesca. It is worth it. We can turn this thing around to make it better for the next generation.

  27. Santoah dhakal

    Well said doc. Keep writing and tell the world the real world of doctors. They have to understand and send some paid vacations once in a while.

  28. DANIELA ALEXANDER

    Someone said we -the medical profession- can be animals to each other. It is amazing how cold and uninterested we can be in our own colleagues. We are undiagnosed and untreated patients. We have no empathy for each other -is all for the sake of medicine, patients and the establishment. We are slaves to the system and its expectations. We preach balance but our own life balance is dead. We have money but no time to be ourselves, reflect and smell the roses. Smelling the roses is what keeps you mentally sane. If you are burnout and if you do not reconstruct, you destruct. The colleges -be their Gp or speciality college don’t do more than demand -money, standards and preach “guidelines”. They do nothing to promote and protect our sanity, health. The patient comes first. I am so sad Dr Bryant died but I am even sadder he must felt horrible in the months before, lonely, hopeless, depleted. I have visited that “land”. Horrible. His death should be a wake-up call. My hat off to you for speaking out.

    1. DrEricLevi

      I totally understand your sentiments. as do many. I hope we can turn the tide around. Thank you.

  29. one

    I’m a radiologist working in borneo. The only private practitioner in the district. Oncall 24/7, full working day mon-sat, half day on sunday. Family in another state, fly back every 2-3 months. For this past 2 yrs I saw my youngest son only 4 weeks in a yr.
    The letter, to me is as clear as day.

    1. DrEricLevi

      I’m sorry to hear that. It’s a tough situation you’re in. Thank you for what you do for your patients.

  30. Amy chiang

    I am lying in bed reading your post at 12.37 am because my exhausted husband who has his fellowship exam in 2 weeks has returned to work. We are in Melbourne now and I can completely relate to this article. Tomorrow is his birthday well actually that would be today. He is going to his old bosses place to study anatomy. One day I tell myself we maybe able to celebrate something together.

    1. DrEricLevi

      Thank you Amy. Yes the exam period is tough. I still get nightmares from it. It’s “a little” better on the other side.

  31. Wessam Atteya

    Well said Eric! I couldn’t agree more, particularly with the administrative and micromanagement parts of our lives. I’ve always been dreaming of getting home tired only of my clinical procedures as a dentist not of reading new admin policies and and filling in form.

    Wessam, a dentist in Melbourne

    1. DrEricLevi

      Thank you Wessam.

  32. snyderjane

    This is so beautifully written, perfectly on the mark and accurate! I am a US dermatologist and many doctors think I have it good (and relative to surgeons I do) but I quit my job after 5 years of practice due to the relentless bureaucratic pressures of patient satisfaction, coding audits, productivity parameters, the EMR, etc etc etc. This completely sucked the joy out of medicine and forced patient encounters to rushed under 10 min appointments followed by hours and hours of charting. Thanks so much for writing this extremely articulate piece! Best wishes to you and your family.

    1. DrEricLevi

      Thank you doc. I hope we can all do something together to turn the tide.

  33. Anh

    Thank you Eric for sharing your thoughts and experiences so candidly. It is so tragic that your story is so similar to so many and for the “lucky ones” we survive literally and get through but so many beautiful talented people lose their lives or their passion for medicine or their happiness and confidence because of the circumstances of difficult training, difficult consultants/ supervisors/colleagues, difficult jobs, demanding and unhelpful hospitals/admin/protocols and challenging patients and a system that makes it so difficult to reach out and get help because that would make us weak and compromise us.

    Your story resonated strongly with me having been through plastic surgery training and really feeling disillusioned at the end of it. We all go into medicine and surgery with altruistic and genuine desires to make a difference and help people but the circumstances of the training and the system deliberately want to break us to see how tough we are.

    The working conditions were tough, the demands to study 10,000 hours whilst working 100 plus hour weeks with managing a marriage and a child were tough but what really pushed me almost to the point of quitting so many times or compromising my marriage was the constant and persistent bullying designed to break us and as high achievers who already place such high expectations on ourselves, the awful feeling of never being good enough was what drained me and then this affected every aspect of my life from my confidence, happiness, stress on the marriage. I honestly don’t know how I got through. I am lucky. My heart goes out to the families of Andrew, Chloe and the other beautiful talented doctors who didn’t get through the intolerable stress and pressures.

    It has got to be better than it is. we have to make it better.
    Does it get better? My life as a consultant has more pressures and stressors but they are just different. I feel I at least I have some more control and it’s the passion for what I do and surrounding myself with an amazing team that helps me keep going. However there are times when I wonder if it is all worth it with the pressures from demanding patients, running a practice, covering overheads , being pulled from pillar to post, missing out on time with the children and the family but I am fortunate in that I have so many supports and I keep going.

    But My heart goes out to all my colleagues senior and junior who don’t see the light and don’t come out of what seems like a relentless shadow of darkness. And don’t have the supports. The medical profession really needs people to speak up to improve the culture and together push for better conditions for doctors and nurses. We need to encourage the notion of looking after ourselves and our emotional, physical and mental health and make time for it or make the system change to enforce this.

    Bravo Eric for your blog and your honest portrayal of how it is for so many. Hopefully through this it will instigate and empower positive changes so the profession and the surgical career can be more inspiring – not just gruelling and stressful.

    1. DrEricLevi

      Dear Anh, thank you so much for sharing. I didn’t realise how this has resonated with so many people. I hope this is one catalyst for us to do something about it together. Thanks again.

  34. Elsa

    Hello:
    I’m a Spanish surgeon and I feel the same. I work at the public health service (here is very strong, very good) and fortunately we don’t have that crazy schedule. But I understand perfectly the problems with paperwork, not being able to start my computer session in less that 10 minutes, the unreasonables petitions from the bureaucrats … For me the most difficult part is the decreasing wellbeing, the personal loss; all the reunions, family parties, friend’s travels you have to miss, feeling that it’s not appreciated, neither by the public or the government, how much of our life we are putting on our work.

    1. DrEricLevi

      Thank you Dr Elsa.

  35. SluttyNurse

    Just laying here in bed, nude, reading your post, after a long day at tha hospital. Thank U 4 sharing.

  36. ROBYN

    Thank you for the article. Couldn’t agree more with your description.

    1. DrEricLevi

      Thank you.

  37. Graham Walker

    If you hadn’t written “GP” or “theatre” I would’ve sworn you were an American surgeon. I thought the admin, regulations, measurements, efficiency and throughput measures were a distinctly American breed of capitalist medicine, but I guess no matter who the payor is, they all want to call the doctor’s shots, huh?

    I would have assumed that there’d be less paperwork and fewer hoops to jump through, because of universal coverage that we lack in the US, but I guess I’m sadly wrong.

    1. DrEricLevi

      Nope. It’s universal. Thanks.

  38. CW

    So true. Nodding my head along with all your words. I’m an anaesthetist, and life is now more balanced post-fellowship, but training was a hard slog, full of those “not good enough” moments. And now, absolutely totally agree about the joy being sucked out of medicine by the administators and the bureaucracy!

    1. DrEricLevi

      Thanks.

  39. Vicky Nelson

    You are so amazing! Your strength makes a difference in so many people’s lives. I wish this was difference.

    As a veterinarian I feel simila, but not even close to the scale you do. There is a stigma with suicide. Our profession has a high percentage of suicide. There needs to be change and discussing it is a great first step.

    Thank you for all you do, you truly are amazing!

    1. DrEricLevi

      Thank you.

  40. Harold Robinson

    I work in the ED where everything is measured. Door to doc, door to needle, door to pain med for long bone fractures, door to EKG, door to admission, door to discharge, etc. But at the same time expecting you to sit down and take time with your patients and answer every question they may ask and address every single concern. Smiling the entire time because smiling has been shown to increase patient satisfaction. All the while documenting everything into EMR to maximize reimbursement and profit. Doing your job well and efficiently isn’t enough anymore. Dealing with just the stress of life and death decisions of the job without all of the other BS is not enough anymore. Knowing all of this how is anyone surprised that physicians are becoming increasingly disillusioned with medicine?

    When I recently changed jobs I was asked to keep a cell phone that belonged to the employer on me at all times just in case I was needed. I told them that I didn’t even own a cell phone myself so why would I own one just for you to contact me “just in case”? Why would you need me after I left the emergency department? That is why I went into emergency medicine so I wouldn’t have to be on call. After going back and forth the compromise was I would have the cell phone on at work but I wouldn’t have to take it home with me. I thought to myself if I had to take this phone home with me then I wouldn’t take the job.

    We have to remember that there are two competing interests when it comes to our work. The interests of the hospital or our employer and our own personal interests. Those interests are often in conflict. If I can’t get away from the hospital and leave most of that stress there when I leave then I will not be able to function in or out of the hospital. I will be a horrible husband and father and eventually a horrible physician. As hard as it is I try my best to not think about work when I am not there. I try and enjoy my time with my family and doing whatever it is I enjoy doing without the interruptions of my work life. For a lot of you that have to take call I realize this may be difficult to impossible. But this is the very reason I chose a specialty where I could more easily leave my work stressors at work. The truly depressing part of all of this is that I don’t see things changing for the better but getting even worse. I would say to all of us to take care of ourselves first or we won’t be able to take care of patients.

    1. DrEricLevi

      Thank you.

  41. Herb

    Hi Eric, thanks for an insightful piece. As a registrar and then consultant, I’ve spent the last 27 years calling surgical, medical and other registrars and consultants for assistance with Emergency Department patients too numerous to remember and often wonder how many stay calm and gracious when it must have been their 100th call of the day. You are of course completely correct that public hospital medicine has become overmanaged by non-medical personnel who only know numbers on a spreadsheet. It’s only been the good will of doctors and nurses that has kept hospitals running for the last few decades. My teenage daughter is keen on becoming a doctor and I must say it’s difficult not to dissuade her from pursuing medicine.

    1. DrEricLevi

      I agree. Thank you.

  42. Tim Leeuwenburg

    Thanks Eric for having the courage, like a few other post-Fellowship senior docs, to talk openly about the impact of our work

    – not just clinical pressures (decisions, patient load, risk of error etc) but more commonly administrative errors … or occasional unexpected calamities

    It’s so important to acknowledge that we are not “superdoc” and to both acknowledge AND explore the vulnerability of the fragile human beneath

    This was topic of my 2015 smaccTALK – line here as relevant to the theme

    https://vimeo.com/130819016

    and discussion here

    http://kidocs.org/2015/07/you-are-not-alone/

    1. DrEricLevi

      Thanks Tim. You’re a legend!

  43. Http://about.me/timleeuwenburg

    This post also on self care – I’d encourage all clinicians to take stock and consider their individual load carrying capacity, their supports and their opportunities for recharge

    http://kidocs.org/2016/08/clinician-self-care-wheelbarrows-batteries-tents/

  44. Selina

    Eloquently written. I would like to share my experience as an anaesthesiology trainee (I have been in anaesthesia for 3years) in Malaysia. Last year I suffered from a prolapsed intervetebral disc with radiculopathy which I was recommended to go for surgery. however I chose the conservative route.i was on medical leave for a couple weeks but I came back to work early because my superior said we were short. I complied despite being on a cocktail of painkillers and could still barely walk 20 metres due to pain and muscle fatigue. Shortly after I came back to work (surgeon said I still have to be on light duty)my colleagues started complaining about how I was only seeing patients in clinic and not doing calls. while I was on leave my superiors and colleagues hatched a plan to remove me from the anesthesia dep and put me in Emergency.they didn’t even have the courtesy to talk to me to ask if I wanted to leave or even check on my recovery. Doctors are indeed animals to each other.

    1. DrEricLevi

      Sadly true. Thank you.

  45. Ben Slater

    Hi Eric, this is a beautifully written piece. First and foremost I truly hope you can reclaim your love of surgery and distance yourself from this concept of a ‘tireless industry’. Secondly thanks for your efforts in publicizing the letter written by Dr. Bryant’s wife. This should be mandatory reading for doctors and hospital administrations alike.

    Over the past few years I’ve been studying for a Masters in Clinical Leadership, it’s been eye-opening to say the least. I have had several insights during my course of study that I believe would be useful to people like yourself who feel a ‘loss of control’ working in the medical system.

    The first is that leading change is not futile. Start small and start realistically, but start to change the way the system works. As I’ve suggested to you in a tweet before, if a consultant surgeon isn’t in a position to institute change, no one is.

    Secondly, hospital administrations have the same goals as you. The care of patients. They have a set budget and a large population of patients that need access to therapies. The State Government puts pressure on administrations to reduce waiting lists and State and Federal authorities set Standards the hospital must meet. I like the concept of corporate empathy, understanding and appreciating the pressures faced by the different governance layers in the hospital. In return administrative bodies need to be transparent about funding and the reasons for their policy changes and standards. In the context of the hospital you are a surgeon who is an employee, you are bound by the rules of corporate governance in the same way as any other employee from nurse to cleaner to anaesthetist.

    Finally we need to take some time to work on our minds. It is commonplace for business leaders to have coaches, who help them to peak performance, I think doctors really could use coaching to their benefit. Especially as we progress from the relatively protected (not discounting the long hours) role of a trainee, where clinical work is our prime focus, to the role of consultant where we are more keenly aware of the limitations of the system. You wouldn’t run a marathon without training your body, why work without spending sometime on your own mind!

    1. DrEricLevi

      I agree with all that you wrote Ben. Lead the way. I’ll be a simple Tonsilman following your lead!

  46. Peter

    Thanks for writing this Dr Levi.

    I’m a Medical Registrar at a secondary hospital in WA and have only really started to consider the subtle stresses that we just accept in our industry.
    I’m not sure if I know of many other workplaces where every few months you get given a new job description with new responsibilities, a new location of work, new co-workers (and new forms and systems), and are expected to hit the ground running. For a time I never really felt like I had that sense of “mastery” that is meant to contribute to meaning-making.

    1. DrEricLevi

      All for the patient. Thank you.

  47. Andrew Cheng

    Hi Eric,

    Very well written piece. Echoes a lot of what we all go through as reflected in all the responses to the article. Having gone thorugh surgical training in UK, Australia, and USA, whilst the work culture may be slightly different, the expectations of a doctor is still the same. Thanks for putting this out there. Let’s hope the culture and support structure changes……

    1. DrEricLevi

      Thanks Andrew.

  48. Conan

    Sir, I take my hat off to you and all doctors. This piece is so spot on. I am married to an ED registrar and see the stress, ridiculous work hours, fatigue and hoops she’s expected to jump through on a 24 hr/7 day a week roster too. Stay strong. You’re all doing a great job.

    1. DrEricLevi

      Thank you.

  49. Anna

    Dear Eric,
    Thank you for your thought-provoking post. I recognise the ‘dark seasons’ you describe – having gone through them myself during my resident/early registrar years.
    Actually it was recognising how much that loss of control bothered me that motivated my switching careers.

    However I wanted to put to you that rather than doctors giving up their clinical careers and moving into administrative or management roles being a bad thing, I feel like this is the key to wresting control back towards the hospital clinicians, as well as improving the patient focus of the conglomerate hospital beast.

    In the hospitals I’ve worked at, these positions like patient flow coordinators and patient safety officers are staffed by ex-clinicians and are the better for it. Instead of targets and KPIs being set by bean-counters who don’t know the first thing about seeing patients, having hospitals run by clinicians is a step in the right direction for improving clinician support and control and restoring some semblance of meaning to the job.
    Hospitals are not going to get smaller or less complex in the future – but I think that what we, as doctors, can do about it, is to take an active role and focus on what we can change for the better.

    1. DrEricLevi

      Thanks Anna. I think many of us are trying to do that but we’re hitting language barriers. Business language vs clinical goals. But we’ll keep working on it!

  50. DrEricLevi

    Ok.

  51. Sofia Huddart

    Your story I think resonates with many of us. So few of us, so little time, increasing patients and interventions.
    I’m going to unashamedly plug one Avenue of support on social media that many have found helpful – search Tea and Empathy (public group) in facebook and view the conversation there. You don’t have to join the group if you don’t wish to but it serves to remind us we are not alone in our struggles as physicians.

  52. Jeremy Chan

    Hi eric, I’m a family physician based in Singapore and yes we do face the same problems as well. This is further worsened by poorly designed IT systems, adminstratively-heavy government healthcare claims protoccols.

    Your article resonated with me very well as I personally feel these are things which gives doctors unwanted stress and loads of responsibilities which actually make no influence to quality of patient care but just solely helps our administrators fulfill their KPIs for the sake of fulfilling their KPIs.

    I was previously in a state run hospital in a general internal medicine department and after 4 to 5 years into practice – i decided that enough is enough.

    Personally, running my own practice has given me more ups than downs. I get control of my work hours, protocols and even type of treatment i want to render to my patients. I streamline my own work processes and adopt a physician friendly IT system – all so that i can enhance my engagement with my patients.

    I have been running a private practice family physician clinic for one and a half years and i can confidently say – that clinically – ALL my patients meet their chronic disease treatment goals. ALL are happy with my treatment and i am happy to see my patients each and every day.

    Governments around the world, and other administrators have to start noticing that healthcare cannot be run like just any other sector of the economy or run like a business looking at profit and loss. It is actually an area where we doctors need a lot of support, and to a certain extent even faith and trust. These KPI indicators, loads of adminstrative protocols to track performance is actually a sign that states view healthcare as a burden. But hey, if you have a well treated population, and happy and fulfilled doctors – the country functions better.

    Many studies have consistently shown that happy doctors and happy healthcare workers results in better patient outcomes. I think it is high time people put what is studied into practise.

    Jeremy

    1. DrEricLevi

      Agree Jeremy. Thank you.

  53. rosshofmeyr

    Great piece of writing, Eric.I think all of us from different specialities identify with your sentiments. We’ve recently had a drug overdose by one of our colleagues, which has left everyone reeling. I’m going to share your blog post with my Department to encourage them to introspect, and to speak out.

    1. DrEricLevi

      Thank you.

  54. Alex Crandon

    Dr Levi, thank you for a great and absolutely true summation of our current health service. As an Oncology Surgeon, now recently retired, I know first hand what you described.
    I graduated in the early 1970’s and probably for the first 15 years the practice was enjoyable and rewarding. I have wonderful memories of a hospital coming into a clinical discussion in the ward office and wanting to speak to a Registrar about a surgical complication. The Consultant stood up and pointed out that any questions about patient management and complications would be between him and the Registrar and certainly did not require the input of an admin functionary with no medical training. He then told the Registrar he was not to speak to admin about the patient and then told the administrator to go back to his office and shuffle his paperwork and leave healthcare to those professionals appropriately trained to do the job.
    As long as hospitals and health services are run by bureaucrats, administrators and bean counters it will continue to get worse. I miss the staff I worked with but not the hospitals.

    1. DrEricLevi

      That’s gold! I don’t think we can do that nowadays!

  55. Ines Boyne

    Very true analysis, especially on how men can bottle their emotions up and cannot see another way out. Loosing self- esteem and the worries about being labelled and talked about by medical colleagues is forever present.

  56. DLG

    Brilliant summary of current hospital practise and well done for being brave enough to give such great open disclosure. As a RN of 35 years and now CNS of 6 years I have seen and continue to see the insanity that is the medical professionals life. I watched a friends family’s devistated by their partners suicide (successful Neurosurgeon) years ago and the pressures have gotten much worse. Its hard to grasp where its going to end..what madness needs to occur before the beaurocrats see sense?? I’ve got out of hospital system to try and find some job satisfaction… found it for a while … but NDIS happened!!! Keep fighting, stay strong n hope there is an influx of some strong Doctors who will fight back!!

    1. DrEricLevi

      Thank you. Indeed you’ve seen it all.

  57. H Singh

    Great article; very true too across the board range of surgical specialties. I’m a back surgeon, and we have a dark issue not discussed in your article………the legions of legal practitioners who earn their living by finding fault in what we do for our patients. Sometimes we end up with unexpected clinical outcomes; not necessarily iatrogenic injuries; and it makes good pickings for the under employed lawyer……making mountains out of molehills…..

    1. DrEricLevi

      I can see that.

  58. Andrew Liu

    Dear Eric, I am a busy Cardiologist working in Perth. Like you I work in both private practice and the public.
    I think you have posted a fantastic piece of writing that highlights issues that have been on my mind too. What do we say to young medical students aspiring to a career in Medicine then? Four weeks ago I had the chance to address a lecture theatre full of students attending a specialist career night. I later put down my thoughts on paper as a follow up letter to them.

    I would be most interested in hearing what you think of it. Please feel free to repost it.

    This generation of doctors has a rendezvous with history.

    Dear Student,
    Thank you for attending the Medical Students of Notre Dame physician’s career evening.

    As you may recall, my presentation started a little different to the others. The other speakers very eloquently outlined a guide to physician training their particular specialty.
    I would like for a moment though, for you to reflect on the state of medicine at present. We are currently at a cross roads of how medicine is being practiced.
    Doctors keen to enter physician training now face challenges that have not being encountered by doctors past in generations.
    What will the future of the practice of internal medicine look like?
    I think it will depend in great measure upon what we all do here right now, on the kind of community that we build, on the kind of attitudes that we maintain.

    By and large, one the biggest obstacles has been overcome by all of you already; that of entry into the medical course itself. From over 2000 applicants only 99 are chosen to study Medicine at Notre Dame.

    We have a good healthcare system but I think we should have a great healthcare system. We have smart doctors but I think we should have even smarter doctors.

    At present, I see three main challenges facing young physician candidates.
    Firstly, those of you that follow national news closely may have heard of the recent suicides of four young doctors who were overcome with the pressures of working fulltime and studying for professional exams. I believe that this have resulted not from deficiencies of the individuals but from deficiencies of the system supporting the individuals. I’m not satisfied that we are doing as much as we can to support our junior candidates.

    Secondly, now than ever, the practice of medicine is being dictated not by doctors but by policies and protocols drafted by those who do not practice clinical medicine on a daily or even monthly basis.

    Thirdly, the prospect of securing a conventional consultant post in major teaching hospital upon completion of your advanced training is currently slim. Within our own department of cardiology at Fiona Stanley Hospital, the majority of consultants are between 35 and 45 years old. You are going to be waiting on average 15 years before any of them retire. If you want to work as consultant you are going to have to envision an unmet need and create opportunities for yourself.

    And yet, you and your colleagues have unparalleled advantages and opportunities compared to generations past.
    You have access to devices and technology which offer unrivaled convergence and connection.
    You have powerful applications and programs that allow you to access late breaking clinical trials, review articles and opinions from leaders in their specialty. You can download them and share them with your study buddies instantly. Gone are the wasted hours of trawling through paper journals in the library and lining up in front of the photocopier. The sharing of knowledge has never been easier.

    Social media and related applications allow you reach out and support your peers. You can organize a study group; convene a private tutorial; initiate a discussion about research and network with mentors all with the click of a mouse or tap on your phone. No one needs to feel isolated if we take the time to support each other.
    Medicine has yet to take advantage of the power of modern digital devices.

    There exist, as yet unexploited opportunities of using simple smart phone apps to help with clinical practice. They cost little to code and they could revolutionize how best practice pathways and guidelines are implemented. All it takes is a little imagination; a small amount of funding and the passion to see a project through.

    The question now is: Can medicine continue to be practiced by junior staff efficiently and compassionately under the most stressful conditions yet encountered? I think it can be. And I think in the final analysis it depends upon what we do here now. I think it’s time we supported each other; used technology to innovate and advance medicine and lastly, take leadership over the policies and procedures that guide clinical practice.

    You don’t have to wait to become a consultant to make a difference. You can do it as a registrar, a resident and as a student.

    To quote the movie Zootopia
    “I implore you: Try. Try to make the world a better place. Look inside yourself and recognize that change starts with you. It starts with me. It starts with all of us.”
    All the best with your studies
    Kind Regards

    Dr Andrew Liu

    1. DrEricLevi

      That’s a fantastic note, Andrew. I see the tide is turning everywhere. The next generation of doctors will push hard to make health care better for our patients.

  59. Shan Douglas

    Dear Dr Eric, Firstly, sorry for the loss of your friend. Secondly, if you have not done so already, I highly recommend, “Terminal Decline” by Dr Mohamed Khadra. He writes very succinctly of the administrative barriers preventing doctors from doing their jobs with a sense of autonomy.
    Best wishes, Shan Douglas. CNS

  60. Rodney Phillips

    Hello I’m not a Dr. or specialist The little training on suicide prevention was a 3 day seminar 15 or 16 years ago, so my resources are a very limited lot.Having said this I want to give each of you doctors, nurses or other professionals what seems is the only way forward when dealing with matters of stress, pain, anxiousness or other things which reach out and eat at the heart of man. When a patient becomes sick, they go to a doctor, (You), they don’t know you, they more than likely have never heard of you, but they trust in you to take care of their life threatening problems because the shingle over your door says “Doctor”and you are trying to meet their need 24/7 on your own.When you were young and growing up you relied on your father to guide you help you, if you fell you looked to him to help you in your need. These are all natural things that could happen to any of us, but we need help to cope in this time of stress to our minds and bodies and just as we believed in our natural father when we were young it is now time to reach out to the chief Physician and let Him take the stress, let Him advise you on your best course of action. Can I say a small prayer for you all because I love and appreciate the pain you are feeling when the natural body starts to wilt. Heavenly Father, Hear the hearts of these doctors whom You have placed in our communities to aid Your children, give them wisdom and understanding, strength and most of all Your love. Amen. Rodney

  61. Jeremy

    So true… our beloved NHS has not quite hit the same degree of demand that you appear to have but is not far behind. On a positive note, there are people out there recognising this and doing something about it. One of the streamed lectures at the International Forum on Quality and Safety in Healthcare in London just a few weeks ago was entitled ‘How to restore Joy in the Workplace’, lead presenter Derek Feeley, CEO of IHI. It is still there and very much worth finding an hour to watch and listen to… if you can find an hour… but if not, forward it on to a manager or two!!!

  62. Trent williams

    Hi eric
    I am a nurse, I just wanted to congratulate you on a really wonderful piece of writing, the problems you mention I think are felt to some degree by all those who work in health. I really do hope a culture change occurs! Congratulations again on a great piece of writing

    1. DrEricLevi

      Many of my nursing colleagues fully understand because they share the same struggles. Thank you for what you do.

  63. Layla

    Hi Eric

    I’m an ENT trainee in the UK (14 minute tonsillectomy!) – I’ve actually left my job and am studying health informatics because I just can’t see the light at the end of the tunnel. Although I have the option to go back at the end of the year I know I won’t. I had a minor car crash that really shook me emotionally after telling my counsultant I was too exhausted to drive but being told to get in the car and drive 40 minutes to a peripheral hospital after a 12 day stretch with 5 on calls as a brand new registrar when I was working late every day as it was to keep on top. I feel immensely sad to leave my patients and my profession behind but I was sick of walking around the hospital at 3 am looking for appropriate equiptment, covering 24 hours on site for sick leave and getting home to no support network because I lived 100 miles from my all of my support network. Due to the yearly rotation I didn’t even have any friends.

    After quitting I think that it took me 1 month to catch up on sleep deprivation and another 2 months to start feeling like my old self. I’m loving my course but leaving medicine has left a huge hole that I’m not sure I will ever get over.

    I wish you the best of luck and hope it works out for you.

    1. DrEricLevi

      I understand what you mean. I wish you well. You did a courageous thing Layla.

  64. Stephen Coppinger

    I’ve shared this as it hits several nails on the head. I was secretly very glad that none of my boys wanted to do medicine, even though I am an umteenth generation medic. But medicine has changed and ‘doctors’ are becoming technician s- a process that will accelerate as AI’s start to outperform humans at diagnosis.

  65. jason

    Responsibility without authority is the cause of our dilemma. By yielding control of our profession and its fee structure to corporations and their shareholders, we have committed suicide en masse. It is just a matter of time before we start throwing ourselves out of buildings (as some workers do in China).

    the solution is to restrict our numbers and ensure that the physicians who are produced can only do the best medicine. By ‘working harder to make more money’ we only play into the hands of the corporate lie that eats our soul. We should refuse to care for cases that exceed our capacity.

  66. Matt

    Thanks for sharing your experiences and thoughts. I’m currently a medical student in the US, and the part of your essay that resonated the most with me was

    “When can I actually find support? I don’t have time to talk to my colleagues about life. I don’t have time with my family. I don’t have time to catch up with friends.”

    This has been the most perplexing part of all of this for me. I have diverse interests. Besides medicine, I love machine learning and software development. I studied mathematics and biology as an undergraduate. I lived in China for a year learning the language. And I’m sure all of these things made me “more competitive” as an applicant. But for how much medical schools talk about how much they seek to find students who “fit” at their institution, I don’t see how I fit in this at all, as do many of my equally if not more talented classmates. Why pick someone with diverse interests and talents so we can give them all up and focus narrowly on one thing all the time, year after year? I’m wondering if I’m not the person they really want – it seems that person would be someone who has focused narrowly on their classwork their whole life. Is it because we look better on paper?

    The most infuriating part of all of this is the number of lectures and emails the medical school sends out about “wellness” and “taking care of ourselves”. I don’t know why everyone talks about depression, suicide and burnout in physicians, residents and medical students like it’s some kind of enigma. From my perspective it’s straightforward – time. Doctors are people too, they have and want to cultivate other interests and relationships. Those things don’t appear out of the ether, they need time to develop.

    On a final note, if you’re a medical school administrator reading this, for the love of God, do not schedule a 4 hour “wellness” session on a Friday afternoon after an exam to lecture us about how to take care of ourselves. We are adults. We know what things we enjoy doing. Give us some time and space.

    1. DrEricLevi

      Stay the course. Despite the downs, it’s an amazing job!

  67. NH

    Very well written. I am a psychiatrist and 11 months out of residency, I relate to all 3 reasons but definitely my work isn’t as grueling as yours physically but it is mentally exhausting. The feeling that administrators don’t even want to acknowledge that you are a physician and do everything in their power to strip you of your autonomy and worst your identity as a physician, it is nothing like I ever expected. I used to write a blog as a resident. I haven’t touched it in 6 months. You are more resilient than I am to do this for so long. My feelings have changed and I struggle with my work. I am so sorry for the physician whose wife wrote the email. We all know the dark side, we just are expected to hide it, so it doesn’t have to be acknowledged.

    1. DrEricLevi

      Thank you.

  68. Ress

    A fantastic blog, add in a couple more issues on the untreated PTSD of dealing with spectacular traumatic deaths as a Dr and you’ll have why I left the conventional Doctor fold.

    I saved myself. RIP my friend who killed himself. For all my Dr colleagues who are waking up and who still remain locked into the misery and the horrific life/work balance – this does not have to be your life.

    1. DrEricLevi

      Thanks Ress.

  69. John pilcher

    I have nothing but respect for all that you do and your outstanding commitment. I thought being a social worker was over stretching people but you and your other professionals go even beyond that. We have the same compliant mess with targets, ticking boxes etc and none of it client focused it’s about administration and targets. This is also seriously effected by poor computer soft ware that requires specialist assistance to physically be available so people can input items in the correct places, it’s farcical. So I have some insight but the continued calls back into work, the lack of down time, time for you and family and friends has got to be a recipe for very poor mental health. Things need to change. You guys need more support and some control over your work life. Take care and remember you can walk away, if that what it takes. Look after yourself, best wishes John

    1. DrEricLevi

      Thanks John.

  70. torch

    Hi Eric. Thank you for such a reflective, thoughtful and highly accurate post. I am a psychiatrist working in the South Australian public sector, and we share many of the barriers and challenges you so clearly articulated. Your post really resonated with me. The somewhat good news at least in our discipline is that our Chief Psychiatrist is trying to bring back structured training to our workforce around compassionate care and values-based practice. It is tragic that bureaucracy and organizational pressures have eroded such concepts to near extinction even in mental health, but there is a drive and mandate to bring it back now (through programs such as Trauma Informed Care and Connecting with People program). I am involved with a handful of colleagues in also trying to bring education around such values to registrar training and even medical school. Its an uphill battle; the spectre of burnout always looms, but at present I feel it is worth persisting with even if there is a slim chance of improving outcomes for patients, families and of course, ourselves.
    In the meantime, I recently wrote an attempt at a motivational post on my blog for the psych trainees. It may be of some interest to you:

    https://juliantoh.wixsite.com/website/single-post/2017/04/15/Why-do-I-do-what-I-do

    1. DrEricLevi

      Thank you for all that you do for the health of doctors around you.

  71. D Smith

    This was a fantastic summary of what it is like to be a doctor in the public hospital system. Thanks for writing it.

  72. L

    Another one of those fields where I believe we should impose constraints on business – ethic constraints. Profit should not be the only goal, it is detrimental to human life & the environment otherwise.

    The industry naturally engages in strategies of influence to promote its commercial interests.

    So in theory, governments have a responsibility to develop counterstrategies to protect us and the common good.
    We should insist that they fight to do so.
    “This is because governments are the guardians of public health; governments are the guardians of the environment; and it is governments that are guardians of these essential parts of our common good.”

    Or at least that is one way at looking to solve this problem which hurts so many people which is ‘bottom line over everything else’.

  73. Anja U Mitchell

    Dear Eric,
    Thank you for sharing your deep thoughts which resonated really with my experiences.
    I have some insighrs to share with you, and our colleagues, which may be helpful and a little out of the ordinary:

    Having trained in the UK, and started my anaesthesiology carreer, I left for Denmark in 1999. I experienced all the pressures and lack of understanding of peers described in this block, and also had had some very dark times. Struggling to work many hours, study for postgrad exams and be there for my 4 children then aged 1-6, I felt I did nothing well enough.

    While Scandinavian Health Systems are far from perfect, there is something to learn from life as a doctor here.

    I can now see my family most days, and have usually control of my days despite being a full-time consultant and engaging in the Danish Medical Association and European Doctors (CPME).

    Why? There is a better understanding of work-life balance here, that doctors are no super heroes, that you can share the work load between doctors.

    That does not come by itself, we medical doctors need to work hard for reasonable working conditions.

    How?
    – stand together as colleagues in the departments
    (example: what would happen, if you and all your surgical colleagues demanded to have control of your own operating lists, having the last say in booking? Requires talking with your colleagues and a negotiation on behalf of all of you with management. But can they afford to say no, if you are agreed?)
    – stand together in medical associations
    – medical doctors need to engage in clinical leadership, to bridge the gap between clinical work and managemenent
    (Clinically grounded leaders often take more sensible decisions)
    – put aside super heroe attitudes
    (All doctors are replaceable, it is a matter of sharing the workload appropriately, training and employing enough doctors, letting doctors do clinical work mostly, less bureaucracy)

    One difficult thing: the patient, which we all are agreed, we want to provide best possible care for, should not become hostage.
    How to avoid this?
    Eg with reasonable on-call rotas, allowing enough time off after on-call, sharing patient care with colleagues etc
    After all, we can all fall ill, with serious consequences for us, our families and patients.
    The only way to prevent this, is to – invest in prevention, that means working for reasonable changes from now on.
    By all means, use electronic means as well, but remember care via social media is severely limited, as personal contact and real commitment can be easily avoided. Commitment is required for affecting necessary and sustained changes.

    I would be happy to share more thoughts on how to improve matters, how to tackle organisational change, so please contact me, either via e-mail or on twitter @anja_mitchell

    My deepfelt sympathies for all who feel pressurised at work, sometimes beyond that which can be endured. For them, their families and their patients, we need to work together for change.
    It will not happen by itself, others will not fix it for us, it is not easy.
    But we as medical doctors, colleagues, friends can make a difference, I hope.

    1. DrEricLevi

      Thank you for sharing this.

  74. Sam Bendall

    Dear Eric,

    Thank you for a very eloquent and accurate summary of the current state of play for doctors working in the public health system. My heart also goes out to Andrew Bryant’s family. The comments above show that this is a recurrent theme. Joseph Noone wrote an excellent blog about maximising employee performance – the three keys to this being autonomy, mastery and purpose. As you said so beautifully in your post, these are what are being constantly eroded by the administrators in our hospitals and it is little wonder the rate of physician burnout is skyrocketing. It would be wonderful to work in a system where administrators focussed on making our job easier not harder, simpler and more streamlined rather than clunkier and more inefficient, more centred around actual patient care, not surrogate measures that mean nothing to anyone other than those looking at numbers in a setting far removed from the bedside. When will the administrators stop being reactive, look forward with vision and actually be leaders? I have been a doctor now for 22 years, a specialist for nearly 10, and I still love medicine. I simply want time to care and the resources to do it well. As far as I can see, that is what we all want.

    1. DrEricLevi

      Thank you.

  75. Nadine de Alwis

    So this is my very first post. I probably shouldn’t be doing this as I don’t have TIME. Eric, as you are aware the FRACS exam is 2 weeks away… I read your post and instantly knew which job you were talking about as I’d just finished my year of pain at that same hospital, unlike you however I’ve had 3 months of TIME at my current position to study for the ‘quiz’. Let’s hope I pass.
    It often comes down to TIME and you are absolutely right. During those dark times I was told to meditate, practice mindfulness, exercise and chill out but when did I have TIME for that? As a trainee you feel so out of control. It’s terrible that some are pushed till the point of no return.
    The bureaucracy of medicine has also been playing on my mind lately. Especially as I near towards consultancy. I’ve had my head buried in the sand (or books rather) and other times been frantically trying to stay afloat. It’s only recently that I have started to notice what the public hospital system has become. We have such responsibility and if something goes wrong with patient care then it is we who are blamed. The buck stops wth us- so why did we lose control? Why do we have administrative staff who have never treated a person run hospitals? Do they think they can run it like any old company, as if that’s all it is? The very fact that budgets are given based one the previous budget expenditure is ludicrous. So everyone gets crazy during End of financial year and bleeds the money. I had a nurse buy a $3000 weigh scales for outpatients just to use the budget so that we would get the funding the following year. What’s the incentive to save?
    I’ve spend countless hours on top of clinical work filling out red tape and I’m already sick of it. I haven’t even started my career as surgeon!
    I’ve asked myself if I would recommend a career in medicine to my daughter- currently the answer would be no. There are no jobs, no respect and the future of medicine is uncertain.
    Whilst I do love my job and count myself very lucky, I’m not sure if in 5-10yrs my junior colleagues will share my sentiments.

    1. DrEricLevi

      Hi Nadine. Yup. We’ve travelled the same road. It’s a conversation that needs to happen. I hope there are medical administrators listening to this.

  76. Pamela Ramsey

    Great job of putting the perfect words to a increasingly horrible situation. I have been practicing for 37 years now. I read it to my husband who just couldn’t understand why I wasn’t happy. He started to cry. He just didn’t understand why I am unhappy. I love my patients and nurses. The administration makes me cringe every time I have to see or talk to one. Even now I worry, will they see this? Know it’s me? Fear for my job? Maybe it would be okay to be fired. But as the breadwinner of the family I can’t stop. I don’t want to let my patients down, I want to help. But I would like to throw the computer, the insurance companies, the administration, the big pharmaceutical industry in the trash. Everything that stands between me and taking care of my patients. Never signed up to be a cog in a large industrial wheel of do more, work longer and don’t complain. I shouldn’t cry driving home from work. CEOs make millions a year, guess that’s what you get when you sell your soul. Thanks for putting it all so succinctly. At least my husband gets it now. Big hugs to you! Thank you.

    1. DrEricLevi

      Thanks Pamela.

  77. marchudson

    Brilliant writing, thanks.

    This from David Brooks recently may be of interest –

    “Thick institutions have a different moral ecology. People tend to like the version of themselves that is called forth by such places. James Davison Hunter and Ryan Olson of the University of Virginia study thick and thin moral frameworks. They point to the fact that thin organizations look to take advantage of people’s strengths and treat people as resources to be marshaled. Thick organizations think in terms of virtue and vice. They take advantage of people’s desire to do good and arouse their higher longings.”
    https://www.nytimes.com/2017/04/18/opinion/how-to-leave-a-mark-on-people.html?_r=0

    Marketisation is thinning out previously thick institutions…

  78. Ken

    After 13 years of medical training all over the world, and 3 years working as a consultant subspecialist in an academic setting, I decided to quit western medicine. My predictable future seemed a copy/paste of my past, being overworked, exhausted, absent to my partner, kids and also to myself. I had no time to find peace.
    Money screws us all. We justify our income/power/prestige by sacrificing ourselves daily.
    Quitting medecine is not selfish. It was my most compassionate decision for the better of humanity.

    When living in stress, our biology and brain change and we cannot see the big picture. We live in survival, always looking for the next task/disaster coming next.

    It has to change. The ressources and expetations we put on the doctors and the system are so disproportionate to the curing potential of western medicine. Seriously.
    We are at crossroads. Only improvement can occur!

  79. ML

    this article sums up how i feel. i am an oncologist and love my profession. i hate the nonsense that comes with it. the other day i asked a patient to follow up in a month and his wife said ” a month?” i immediately got defensive and said “i know that’s really soon but i need to keep a close eye on him because of chemo” she said “no we want to come back we love seeing you when we talk to you we have peace and comfort”., i started to cry after that visit. i am just so used to being criticized for everything , not seeing enough patients, not reviewing labs quick enough, not writing orders fast enough, etc etc. it never occurred to me that i ever do anything right how sad is it that that one act of validation meant so much

    1. DrEricLevi

      I’ve been there too. Surprised at the gentleness of my patients.

  80. Dan F

    I’m not a physician, just an analyst at a university hospital, but I greatly appreciate this perspective. I had wanted to become a physician before realizing I didn’t want to live the demanding life it requires, but I love healthcare. I’m young in my career, and I hope I can help reduce the burden on clinicians from the administrative end throughout my time. Thanks again for a detailed and frank view.

  81. […] an outpouring of emotions. I didn’t plan on ever ‘going viral’. But since I wrote ... ericlevi.com/2017/05/17/the-dark-side-awakens
  82. claire palmer

    What a great letter you have written! The other thing missing now is GRATITUDE. Just a small thankyou from your workplace, patients, colleagues etc can make all the hard times seem better. Keep going! Thanks for your letter

  83. Rashmi Dixit

    Charges nurses and clinic nurses breathing down your neck with judgment and impossible demands
    – but if you respond with anything other than subservience, if you show any type of frustration or anxiety or defensiveness – you are abrupt, rude. Switchboards constantly misdirecting your calls, taking up precious time, a simple attempt to get hold of a colleague turns into a farce. Again, if you voice betrays any hint of frustration – you are an arrogant rude doctor. Patients get frustrated and nurses pressure you by repeatedly asking how long you will be, not understanding it is out of your control – a stressed or defensive response labels you a bad person. Doctors not answering their pagers, finally you speak to their dismissive, sarcastic seniors.

    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.

  84. medgyne

    Wow this is so true ! It makes so much sense and not once to we realize this is abnormal. It’s like everybody else is doing it so it must be fine .

  85. Michele A Scott, MD

    Well written and right on the mark. Loss of autonomy hurts more than loss of social status, income, or even the title “Doctor.” The loss of these things are regrettable but not overwhelming. The loss of autonomy, control over one’s destiny, basic rights to eat, sleep, bathe, and relieve oneself as other human beings at our level of education and experience is disheartening to say the least and dehumanizing to take it a step further. Sometimes suicide seems to be the only answer. Everyone’s favorite medical show, MASH, even told us so, every week in its well-known musical theme song, that “Suicide is Painless.”

  86. RJR

    I think the way doctors treat each other leaves a lot to be desired. I’m leaving my chosen specialty training because the self appointed gatekeepers have decided I’m ‘too different’ and don’t fit their mould regardless of my clinical performance and research output.

    1. DrEricLevi

      I know what you mean, RJR.

  87. Jill Becker, MD

    Reading this just helped me to piece together a horrendous event from residency and the postpartum depression I experienced three years later. The shame I have lived with secondary to leaving my residency has haunted me for almost 20 years. Thank you for your post. I suspect it will be instrumental in my continued healing process.

    1. DrEricLevi

      Thank you Jill. I wish you well.

  88. Anna

    Dear Dr Eric, thank you for your very insightful post which seems to have resonated with a number of health professionals, not just doctors. And I’m one of them. I am an allied health professional working as a mental health clinician in one of the largest public hospitals in Australia. I am also an allied health professional who, six years ago was diagnosed with Bipolar Affective Disorder.

    About eight years into my professional career, I had become increasingly frustrated by the administrative burden to which you make reference. The new policies, practice guidelines, protocols, best practice standards, KPIs, forms to complete to justify just about everything one does or does not do. Again, most of the people writing and imposing these administrative requirements have never worked in clinical practice – they’ve never seen a mental health patient in an acute psychotic state but they are assessed as being qualified to write ‘standardidised’ policies on how to best manage such patients in ED. And isn’t this concept of having ‘standardised’ practices across the State an interesting one !. It’s about adopting the same practice for every patient, on all occasions in both small and large public hospitals across the State. This is based on the assumption that every acutely psychotic patient brought into ED for assessment are ‘standard’ cases where ‘standardised practice guidelines’, if followed, should result in a positive outcome for the patient and for the service, I presume. How are the unique circumstances around every patient’s presentation to ED meant to be managed? The ‘standardised’ practice guidelines do not talk about clinicians being able to exercise their professional judgement.

    I decided to address my frustrations about the above and proceeded to get a job in the Health Department’s corporate office as a policy advisor in an attempt to positively influence the polices, guidelines, legislation etc about the delivery of mental health services at the front line. I can say that I had some ‘wins’, in that my background as a mental health clinician was valued and my input reflected in a handful of administrative tools/policies that were implemented while I was working in the role. But I soon found that whenever high profile sentinel events involving mental health patients occurred, politics and knee jerk reactions were the only dominating factors influencing the issuing of memorandums about urgent changes to clinical practice. This was a far too common occurrence and I didn’t feel comfortable being the one asked to write those memorandums. Thus four years later, I have returned to clinical practice. Sadly, I’ve found that, while 10 years ago, the outpatient consulting rooms were always all booked out by clinicians seeing their patients. Now, those same consulting rooms are mostly vacant at all times. The number of mental health patients have increased but the frequency at which they are seen has been significantly scaled down by health professionals who now spend most of their times sitting in front of two computer screens completing administrative tasks. They include administrative processes put in place to support best practice. Sounds good, but when do we now get the time to actually engage in best practice !. It’s just nonsensical.

    1. DrEricLevi

      It saddens me to see the decline. Thank you for doing what you do.

  89. Mindy

    Thank you for the post. It resonated. I too am a physician. I struggled with the demands from the beginning of clinical medicine as a student. I always thought it would get better, people told me it would. I struggled through internship and internal medicine residency. Residency was a nightmare. We didn’t have the same issues with control schedule but had the same time demands. The administrators who dictated process and had little understanding.

    I lost contact with very close friends over the years and have been trying to rebuild. Though i am secure financially I do sometimes wonder what my life would be like if I made a different choice as a student. I have gotten out of hospital practice and into reseaech with some sessions at the hospital and in private practice and am much happier.

    In the end i don’t mind so much because I paid my dues and it gave me options and the ability and means to explore other interests. Medicine is a calling but I had to find a balance, weigh the pros and cons of the hospital life. Today I have found a balance which may be different tomorrow.

  90. C Card

    As a physician, you are told “what did you expect?” or “you wanted to be a doctor” when you deign to complain/vent about how exhausted/frustrated/overwhelmed you are. You are told that you are never doing enough. You should be seeing more patients, you should be seeing them faster, you should be doing research and publishing. If anyone of us ‘asked’ for help, we fear that we could be terminated without cause (a clause in our contract with the AHS – our provincial health care body)

    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. I am an lung oncologist, and about 95% of the patients that I have will succumb to their cancer while under my care. And I love what I do – even the hard things like talking to a patient and their family about nearing the end of their life and what their wishes are at the time.

    Thank you so much for sharing your experiences. You expressed how many of us feel and why so clearly.

    1. DrEricLevi

      thank you.

  91. Ditzy

    Hi monkey I finally found your page after ages! Guess who hehe. Love this post so much I will have to bookmark your website and read everything from start to finish one day.

    So glad you have written honestly and passionately about the struggles we face. Thankful for brave souls like you who write about issues eloquently without making it seem like we are a bunch of whiners.

    I’m on call every 3 days and each call lasts 36 hours or more. Not quite as dire as yours but tiring enough that i have problem focusing and the thought of quitting is very very very real.

    But gonna hang in there for a bit more and hope things get better. Stay strong!

    1. DrEricLevi

      Stay strong Ditzy. Stay the course. It is worth it.

  92. JBM

    Oh my goodness, you’ve hit the nail on the head. I’m a clinical pharmacist in a busy hospital, and I’ve got 26 years experience. I can attest that the stress of push push, hurry hurry stat meds, wait the computer isn’t working, coupled by an ever increasing workload, more medications than ever, and more complicated patients is leaving pharmacists in situations where we feel completely completely overwhelmed, burnt out and that we are leaving patients at risk, feeling like we’ve missed something crucial. The order sets that were supposed to improve care are causing havoc as multiple drugs are ordered on similar but different protocols (ticagrelor on one, clopidogrel on another). Which order set came first?! Multiple specialists ordering two different anticoagulants, nobody has time to be thorough to see what is currently ordered. I’m worried I won’t catch something because of the massive volume of orders coming through. No time to think!
    Can’t really talk about it to the others, who are equally busy putting in long long unpaid hours, “that’s just the way it is”. I literally feel like a panic attack is coming on, but you don’t have time for it, so you mentally go “breathe, breathe”. I’ve been coming home in tears, weekends off spent fretting about going back. I never used to have a mental health problem- but the last 2 months have been hell and I want to retire at only 52 and with all this experience I can’t cope? How can the newbies who are still learning!

  93. Joseph

    Nothing, and I mean No Thing would ever cause me to kill myself. The day my first career causes you to resiliency and sense of purpose is the day you should move on to something else. Blaming it on the system is not the way to deal with the issue. Doctor’s around the world work in some of the most inhospitable areas of the world (ie Syria) My suggestion is, if things get too hard to bare then it’s time to move on no matter how much money or time has been invested. Join doctor’s without borders or something of higher calling. Soldiers run into battle, Firemen run into burning buildings. Goes to show a high IQ does not equate to resilienc. I’m sorry, I don’t feel remorse for people like this and people who make excuses for them.

    1. Alex J Crandon

      Well Joseph you show absolutely no understanding or insight into the situation that is being talked about. In the inhospitable places you talk about, including working with Medecins sans Frontieres, the aim of the process is to maximise patient outcome and doctors are supposed to do what they were trained to do, look after patients. What everyone here is talking about and which you seem to have totally and absolutely failed to grasp, is the current situation in hospitals in first world countries where the doctors are not allowed to treat patients as they believe best but are expected to follow hospital protocols and procedures often written by people with no first hand knowledge of what they are dictating. Patient outcomes are not the first priority. Efficiency and cost effectiveness are the order of the day and if the patients come out alright then that’s an added bonus.

    2. Andrea Pullar

      Joseph, I am truly saddened by the lack of empathy you are showing for someone’s situation that you truly can never understand. Perhaps this man had been resilient beyond most people’s capabilities all his life and then one day his body and mind simply could not do it anymore, and it happened so quickly for him that there was little time to pursue the ‘something else’ that you talk of. Here’s hoping that his passing may serve as a reminder to all who come across his story that time is truly a precious commodity, or maybe there is another lesson entirely in his story. Reading the many stories on this blog has been truly enlightening and I am in no way connected to the medical profession besides being a rare patient. I hear stories from people with honest motives and the genuine interests of their patients at heart and it fills me with gratitude that such wonderful people exist and I encourage all of you to keep at whatever you are doing in the best way that you can, in whatever capacity you can. It truly sounds like the system has become a monster that no one, not even the administrators know how to change or control, and I hope that the people who have the power to bring about change will pursue it for the benefit of all.

  94. SmallViolin

    Thanks Eric
    Within the last few days I’ve been told by admin that i am greedy… for always wanting more emergency time to operate on patients that have been waiting for days

    Within the last week, I have been told by family of a patient that I was a liar, blamer & unsympathetic doctor…. For a system error that our team had partial responsibility for, that i had aoologised for.

    Within the last few months I have been told by a boss that I was disorganised… Their operating list finished late because I did not send them an assistant. Instead I was juggling tired worn out junior staff who were covering sick collegues to run an overbooked clinic.

    Within the last year, I have had my soul crushed by a bully at work. The complaints process lead to my decision not to formally file it because it would’ve become public and I would have been ostracised for it.

    I am determined to continue practicing medicine with compassion, lead by example and always give 100%.

    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.

    1. DrEricLevi

      I’m so sorry. I totally get what you mean.

  95. Mirra

    Very powerful words. Im an Ob/Gyn resident in Israel and all I could think while reading your narrative is that Im so grateful our medicine is not like that. You are welcome to come and join us 🙂 decide over your schedule and your patients and enjoy meaningful connections with them

  96. N

    Very well written article.
    I agree and sympathise wholeheartedly.
    As a nurse of 13 years, I have seen Healthcare decline under the never ceasing administration processes, trying to achieve unachievable numbers, benchmarks, KPI’s, protocols, policies, etc. All having been written and dictated by non-clinical staff, who you never see, and have no idea or have lost the sense of what it is like to not be able to look after your patients as well as you would like to.
    It is so deflating and demoralizing to feel the pressure of these things to the detriment of being able to spend time with your patients. To provide great Healthcare, in a way that’s important to each patient (individual, holistic care, one of the first things that was taught to me).
    Now the push is coming from EMR. A slow, non user friendly system that takes up to 90 seconds to log into every time you want to look at something (trust me I’ve counted). I feel sick at the amount of prescribing errors I’ve picked up, and also for those I may have missed. I spend my shift trying not to kill or harm my patients because of a system that is flawed. It’s turned the most kind, compassionate and well meaning health care providers into stressed, angry, overwhelmed, frustrated staff, who can do nothing except look and want to scream at a computer screen instead of the looking at and talking with patients.
    It’s so sad.
    I feel for the doctors out there, and all of my frontline Healthcare colleagues.
    And I feel for the patients.
    Look after yourselves and each other.

  97. […] The dark side of doctoring. A must read blog post by Eric Levi reacting to yet another recent doct... scanfoam.org/good-doctors-behave-badly-part-1
  98. Julia Tillung PhD

    I commend you on being so honest and courageous in writing this piece. My daughter is studying Medicine and my niece is a medical doctor. So I see the pressure and the extreme long hours they are spending on studying and working already so early in their careers. It does concern me the level of pressure doctors are under from the start and the lack of mental health support they have available. It is fantastic to be speaking openly about these issues, breaking down the barriers and coming up with supportive solutions so doctors don’t feel threatened to discuss their mental health.

  99. […] to trigger an outpouring of emotions. I didn’t plan on ever ‘going viral’. But since I wrote T... medicalrepublic.com.au/dark-side-doctoring/9065
  100. Grace Fan MD

    So eloquently written. Thank you!
    You are able to capture and express exactly what so many of us feel. I’ve been a pediatrician in the US for 26 years; in private practice until our practice was bought by a bureaucratic hospital system 2.5 years ago. Now I’m an employer.
    While I still absolutely love being a pediatrician, the business of medicine is utterly destroying the art of medicine.

    1. GSWood

      Just an employee..Overworked, burnout and replaceable…..until thoughs who can’t do are stop running professional lives in the name of “efficiency” it will only become worse….

  101. LJ

    Thanks Eric. You have voiced the pain of being a happy doctor which lot of us are! I am paediatric allergist in rural Victoria.

    Over decade/s+ of basic and specialist medical training, most of us ignore the very principles of good physical and mental health for ownself irrespective of our learnings about better health. It was nt until I took a career break to care for my young child when I started to realise how me and my paediatrician husband had kept healthy habits away during our ‘career’ build up. Not only we did nt care for ourselves, we never stopped to think how our daily routines were not good for environmental health where our future generations will live their lives.

    I have now been working part time for 3 years to get more out of work life balance . At times it becomes very tempting to earn more money by working more hours, something which is in such easy access. Instead I choose to use my unpaid hours to deal with overwhelming admin responsibilities in a salaried job rather than using that time to earn more money. As you said, poorly supported admin workload takes some pleasure out of my work gratification too. Better IT system is the way forward to improve quality and quantity of care without weighing down upon doctor’ s family time.
    I think its time we all look after ourselves to keep providing good care to our patients for longer.

  102. […] is suffocated by bureaucratic burdens from Health Administrators. Read the comments from Episode 1: ... ericlevi.com/2017/05/20/restoring-hope-and-humanity-to-health-care
  103. Alex J Crandon

    LJ, You have done the right thing. A couple of months ago I moved into semi-retirement and it was the best thing I’ve done for a long time and one that should have been done years ago. We do need a better work/life balance.
    The only thing I would otherwise comment on is your statement that ” Instead I choose to use my unpaid hours to deal with overwhelming admin responsibilities in a salaried job ……….” As long as you use unpaid time to do what should be paid work, the more the bureaucrats/administrators believe we can do the administration in the allotted time, of which of course there is generally none.
    Some time ago I stopped working for nothing. When Admin asked why things (paperwork) weren’t being done I asked them to identify for me the time allocated for this administrative work. Of course they couldn’t and so they decided that they had better allow some paid time for the paperwork or none would be completed.
    The longer we do this for nothing, the longer will Administration expect us to continue; please for the sake of our colleagues don’t do it.

    1. Stephen Coppinger

      Absolutely right. For years I tried to get my colleagues in the U.K. to take a stand but to no avail. Many years ago the managers used to accuse clinicians of ‘shroud waving’ when they pleaded for resources. Later, they regularly relied on our compassion and professionalism to impose more work (in the shape of targets), more paperwork and loss of autonomy, confident that most would not stand up on their hind legs and act like you have. If you look at the sad history of the demise of autonomy and professionalism in medicine you must (certainly in the U.K.) look at the supine attitude of the majority of medics. My generation are not victims: their inability to stand firm is at least partly responsible for current situation.

      1. Alex J Crandon

        Stephen you are absolutely right. Trying to organise doctors is literally like trying to heard cats. Why this is the case I wont go into. However, while the doctors themselves can’t work as one, I am appalled at the disinterest and apathy shown by representative groups such as the BMA and the Australian Medical Association (AMA) to say nothing of the specialist Colleges who are supposed to be primarily driven by maintenance of standards.

        While a large proportion of the profession are constantly appalled at the useless, time and money wasting bureaucracy that constantly erodes our time, our professional representative groups appear to pay no attention at all. These bodies pay lip service to many of the problems. They encourage such things as work/life balance but exhibit no objections to the increasing paperwork that erodes our Quality of life.

        In Australia I can remember moving interstate (New South Wales to Queensland) about 25 yrs ago. At that time all I needed a copy of my NSW registration and identification. I went to Queensland’s State Medical Registration Board and once my paperwork was confirmed, by a phone call, I was Registered in my new State to practice. I then attended the hospital where I would work and they asked to see my Qld Medical Registration which showed I was a Registered Medical Practitioner and a Registered Specialist. I was then welcomed by a small hospital administration, all of whom had a Medical background and many of whom were in active Staff Specialist practice, and told I could start work the following week. The presumption was, that if I had my General Registration from Queensland Medial Board and I also had Specialist qualifications from the Royal College of O&G and from Royal Australian College of O&G then I was a recognised Specialist in the field of O&G and could do my job in that Specialist field.

        Several years ago we did away with State based Registration and replaced it with a National Registration. This was done in part to simplify the problem of working close to a State border or in more than one State where every year you had to re-register in two States and pay fees to both. The new National Registration process meant we Registered once and it applied national wide.

        Not long after that every hospital (both public & private) decided to introduce hospital based Accreditation and Scope of Practice. This effectively re-invented the wheel that belonged to the National Registration organisation, only the hospital based one involved 3 – 4 times the paperwork which included everything that the National Organisation had already done. This was further aggravated by the fact that if you worked at more than one public hospital under the same Department of Health, all of these individual hospitals demanded you do their own hospital based accreditation and Scope of Practice. If you worked at a few different private hospitals, albeit run by the same private health organisation, each hospital wanted their own hospital based paperwork; it wasn’t good enough that you’d done this at hospital A. Hospital B would generally not accept a copy of the paperwork you had provided to Hospital A. Hospitals, usually private, are now asking for certified copies of initial degrees, College Diplomas and identification which is extremely time consuming.
        Now the National Registry organisation is pushing on with a process of introducing some form of re-assessment, that has already as I understand, been trialled in the UK and was extremely onerous and accomplished nothing useful.

        Not only is all of this paperwork extremely tiresome and time consuming, taking us away from our families and our patients but no one has as yet shown any evidence that it accomplishes anything that benefits the outcome of patients. All it seems to do is provide quasi protection for hospital administration and in the process employ innumerable bureaucrats to shuffle these papers and whose wages/salaries consume an ever increasing proportion of the health dollar which is much more needed at the coal front. When renewal is due it isn’t good enough to ask us to sign a declaration to the effect that nothing has changed. No! They send another 14 page totally blank Application form by email and tell you it has to be submitted electronically with all of the supporting evidence/information scanned in. Too bad if you don’t have a scanner because they refuse to accept it on paper.

        The examples of this are almost endless; asking senior surgeons with 30+ years experience, to scrub under the watchful eye of a nurse who will assess whether or not they think they are doing it correctly; this is not only demeaning and unprofessional, it’s offensive. Demanding senior staff do tests to demonstrate their ability to undertake processes/procedures they would never do.

        Meanwhile, our professional representative groups, be it the AMA or the BMA or the Specialist Colleges sit n their hands and say nothing about their members problems. They certainly don’t stand up and say: “No! Enough is enough until you can show some evidence that this improves patient outcomes”.

  104. Dobbo

    Eric,after reading episode one,my wife said that could have even me. Thank you for this timely article that shows how vulnerable we all are when the circumstances collude against us.

    1. DrEricLevi

      Thanks Dobbo! You’re the legend that has taught me well.

  105. Jennifer

    Hi Dr Eric and all.

    Thank you for a beautifully honest article, one that has brought up much for those who have read this. As both the article and the comments what I could feel is that healthcare is sick, especially when you read about how we are with each other as health professionals in healthcare, regardless of our role. I work as a registered nurse and have a growing appreciation and respect for my medical colleagues and visa versa. I had a GP call me the other day, just to talk about a particular patient. We have never met face to face, but we have connected on the phone many times and what we had was a very supporting conversation for both of us.

    Unfortunately what we see and get told about in healthcare is what we need to improve on, what we need to do better. We rarely get confirmed for what is in fact quite incredible. Lets face it we know that we all do amazing work and than none of us would be able to do what we do without everyone else in our respective teams. However even within those teams there is the poison on jealousy, comparison, competition and that fact that a lot of us are just plain exhausted and the impact that this has on all of our relationships.

    We know that the usual fixes don’t work as we see them come and go and often come back again. But we really can’t approach what is going on in health with the same approach that which created what we currently have. Otherwise it’s more of the same.

    However with all of this and with all that has been shared what I can mostly feel is that we actually don’t deeply deeply appreciate who we are, and what we have chosen to do in our life. We have chosen to step into the mosh pit of life and commit to people day in and day out. It’s more than the function of whatever job we perform, it’s that we have chosen this and that what we bring and offer is very needed.

    Yes we all have particular skills related to our jobs, but the function of this has become more important that the quality of ourselves that we bring to our work everyday. This needs to be nourished, supported and grown everyday, much like the skills that we develop. It is of no less importance. When we nourish and support ourselves as people, this then very naturally extends to our work and we become less and less overwhelmed with all the other demands that are placed on us. It does mean that we won’t be incredibly busy. But what is does change is how we are with ourselves in that busyness.

    While we all like to ‘see’ the results of our work and ‘see’ what that brings to a patient and their families, its the quality of what we offer as people that we have a lasting effect, and may only seem small on the outside, but can be quite significant for the person in their whole life. This comes from nurturing and caring us first. Then we bring that quality to all we meet and do.

    In appreciation
    Jennifer

    1. DrEricLevi

      Thank you.

  106. Barbara

    Hi Eric!
    I am moved that finally a doctor has voiced out what we teachers have felt and gone through all these years. Any profession that involves contacts with fellow humans is bound to suffer like this when those up there who are not at the front line stick their sticky fingers into our work.

  107. Christy

    I think thinks a wonderful piece.
    But are we doctors ready to make the changes that need to happen a reality. Are we willing to accept that we are not super humans. I think we are to blame for the predicament we find ourselves in and we need to be the change agents if we really believe there is a problem. And yes I do think there is a problem.
    I am 56 years old and have been practicing since 1991. I have decided that I will not do on Call as it conflicts with everything I try to preach to patients about quality of life. I am not advocating everyone does that but we need to take a stand.

  108. […] Episode 1: The Dark Side of Doctoring […]... physicianonfire.com/sunday-best-5212017
  109. Mark Ready

    Dear Eric
    Thanks for your letter. As a radiologist my life is nothing like yours. Not as busy or stressfuI, still have a degree of disatisfaction mainly due to commoditisation of radiology. Most number of cases in shortest possible time at the chespest price.
    All the compliance rules are a real pain.
    The night call for spurious CT scans driven by the ridiculous 4 hour rule in Emergency departments has driven me to distraction. So much so at 64, I have withdrawn from overnight call.
    Mark

  110. […] In the spirit of learning through social media, I’m inspired to follow up on Dr. Eric LeviR... nursejess.com/the-dark-side-of-nursing
  111. […] is suffocated by bureaucratic burdens from Health Administrators. Read the comments from Episode 1: ... medicalrepublic.com.au/restoring-hope-humanity-healthcare/9106
  112. Burned Out

    Hi Eric,
    I am a critical care fellow physician in the united states. I stumbled across your blog at the perfect time…as someone who is utterly tired and exhausted, burned out and unable to shut off my mind and looking at Facebook, trying desperately for a way to decompress from my work in the ICU.

    I relate to you very much. I cannot remember my last day off, I have missed so many holidays I have lost count and honestly don’t want to know because it makes me depressed. I was unable to not only call my mother on mother’s day, but haven’t spoken to her in months. I struggle to cook, clean, laundry. I am required to do extra medicine things outside of my constant daily and call work load (case reports, administrative burdens, schedules, reading the current literature, etc) and struggle to balance it all. I can never go home and just be home, theres always more work to do. In fact, most days I struggle to eat, pee, shower, and keep up with laundry. I ask my patients to be healthy when I myself am not. My friends are only my work friends because there’s no time to see anyone else that I used to be friends with from high school, college etc. I live apart from my husband because my training for fellowship required me to go to another state. I know that my job negatively affects my marriage at times. I stay long hours beyond what I’m technically scheduled, because the patients need me and there’s no one else to cover. In the ICU, I deal with death routinely and last week had a patient’s family scream at me for not pushing enough medications to stop their loved one from breathing all together. I am often the whipping post for families grieving and looking to take their anger out on something and someone. I have been hit by a patient before. The security never comes as fast as you need them and no one prepares you in medical school for the emotions that go through you after you’ve been hit and/or kicked by your delirious patient. I was the first one to ask a metastatic cancer patient (a true failure in our medical system that no one else before me had asked), in her 30s and similar in age to myself, whether or not she wanted to fight anymore, and then held her hand when she died later that day. After she died, I had to keep going without a breath of fresh air or any acknowledgement of my own inner feelings about her death because there was more work to be done and more people needed me. I watch patient’s I know will never leave the hospital slowly die and suffer for months. I don’t remember the last time I slept for consecutive hours in a row without my pager going off, or waking up because my pager did not go off and thinking I must have missed one. I watch my colleagues make mistakes. I myself make mistakes and no matter how small or inconsequential, they eat at me. I take my home with me emotionally and can be emotionally wrecked for days or even weeks, it affects all aspects of my life. I get burned out, yet it is considered a sign of weakness to admit that, and the “resources” that exist are a badge of dishonor if you use them. People talk about you and judge you if you ask for help with your work load or that you need a day off because your sleep deprived. Sometimes I worry about my safety with driving home after a long call shift. I had an off service fellow tell me that I am not the same person I was when he met me a year ago and that I no longer smile and laugh like I used too. He is right. From day one of medical school, through residency and now fellowship, I have been molded into a different person, for better or worse.

    You put into words everything I’ve been feeling but trying so hard to suppress, trying to pretend that everything is fine and that I can be a superhero and do it all, all the time when really I get burned out. You made my feelings normal, and I am very grateful for that. Yes, I know my job is worth it, and I would choose it again in a heart beat. I also know this current state will pass like it always does, and it will again come back around again. Thank you for normalizing this for me, and for allowing me a place to post my own similar story.

    1. DrEricLevi

      I know exactly how you feel. We’re in this together.

    2. DrEricLevi

      Thank you for sharing. It helps us all to realise the stress we’re under.

  113. […] week I came across a blog post titled The Dark Side of Doctoring written by a Doctor name Eric Levi... https://chartingalong.com/2017/05/22/medical-professionals
  114. De Waal Smith

    All comments are “spot on””
    I’m an ObGyn. Love my job
    Feel the same : “moulded into a different personality ”
    Now that we really can contribute to our patients wellbeing/health , we feel like retiring because of all above.
    My 3 children are all in Med school. Why?
    I think they still think they can spend 90% of their time helping people.No easy solution for our profession.

  115. […] I came across two stirring posts  about mental health in the healthcare profession.  Dr. E... huddlepoints.com/2017/05/23/suicide-among-nurses-and-doctors
  116. […] being silly. The more we talk about this the more we can end the stigma, the more we can bring this ... ericlevi.com/2017/05/30/socks-for-docs
  117. […] being silly. The more we talk about this the more we can end the stigma, the more we can bring this ... palliverse.com/2017/05/31/crazysocks4docs-on-june-1st
  118. […] The Dark side of Doctoring is an insightful blog written by a surgeon. The common themes that push ... kidsaregifts.org/2017/06/03/day-952
  119. […] is the article about the dark side of doctoring by Dr. Eric Levi. I am excited to have him as our gu... doctormoneymatters.com/episode-13-charles-cochran-md-life-of-a-med-student
  120. SA

    Thanks for such a wonderful blog. It clearly depicts current situation. We doctors are not in control of our days , our days are dictated by numerous managers, health care administrators and IT managers . They have never worked as doctors but they impose all these rules , regulations and protocols . I am a physician and have literally no say about my Clinic . As somebody else does booking and hospital has decided that I should see x,y, z. number of pts in a clinic . A person comes and sits in my clinic and counts number of seconds I spend seeing a pt , another person comes with a clipboard to see whether I am washing my hands or not and then another person comes and tells me that they have installed a new software and guess what people who has made that software has never done a Clinc so it’s another crap software ……… it goes on and on…, no time for family …..my marriage broke down because of my job and now cannot find anybody else as has no time , kids are angry at me because of marriage break down and I have to say they don’t want to become drs as they see me as a slave of healthcare industry’…,I have no rights as I cannot control my own day

  121. […] Instead he asked the 3rd year and myself “have you read Dr. Eric Levi’s “The Da... thebookofoi.com/2017/08/13/doctoring-depression
  122. […] in BMJ ” Why has Medicine become such a miserable profession?” says it all!  ” Th... pagalavan.com/2017/12/13/for-future-doctors-are-we-the-last-of-the-jedis
  123. A. Tamilarasan

    I am a retired anaesthetist, but working part time just two days a week in the NHS in the UK. I had been through similar circumstances in my younger days! But the patients were grateful, there were no managers to tell the clinicians what to do and how many to do. Though busy it was satisfying and gave a sense of achievement. In fact there was a lot more surgeries done on any given day than the present day. Healthcare workers were happier then.
    Then the American capitalism and corporate culture were introduced by successive governments to bring in more and more supermarket style managers who think that conveyer type business model should work in hospitals. Tick box culture is rampant, common sense has been thrown out of the window, policies and procedures are dictated to the detriment of mental well being of the workforce, inefficiency in the total care of the patient. Private company healthcare is going to be not affordable to the lower earners and chronic illness suffers. Politicians would fill their pockets with “gifts” from these big companies and corporations.
    I think healthcare workers ( doctors nurses and all the rest in the UK, Australia and NZ and the rest of the world) should rise up in unison to fight against this company and corporate hijaking of healthcare.

    Dr. A. Tamilarasan

  124. […] on February 25, 2018March 25, 2018by Examprof Eric Levi outlines the Dark Side of Doctori... https://expokingz.ga/2018/02/25/what-kills-doctors
  125. […] to be with and work with. So like a good Generation X doctor, I wrote a blog. I titled it the Dark S... ericlevi.com/2018/05/13/broken-doctors-broken-systems
  126. […] problem of physician mental illness and doctor suicide is a taboo in many places. It’s a well ... ericlevi.com/2018/06/03/crazy-socks-4-docs-what-next
  127. Heera Singh

    Dr Eric u r doing a great job . This part of life of a doctor is missing in every article . You took a challenge n u summarized it beautifully . Hope so this article of urs make impact on our lives , so that, we can manage our family well

  128. Penny Toomey

    This is so true and seems to be evident across the western world. I am not a doctor but was an occupational therapist. After nearly 40 yrs I had give up. I was going the same way. Took my retirement at 56 before the job took me.
    Thoughts and blessings to all who suffer with these relentless jobs.

  129. Karen Woolbright

    Beautifully elucidated! It’s bizarre how although the process is not the same here in the Philippines but the urgency and stress of the day is so similar it’s almost like I’m working with you…

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