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?


201 thoughts on “The Dark Side of Doctoring

  1. 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.

    Liked by 1 person

  2. 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

    Liked by 4 people

  3. 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.

    Liked by 1 person

  4. 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.

    Liked by 3 people

  5. 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.

    Liked by 2 people

  6. 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!!

    Liked by 1 person

  7. 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…..

    Liked by 1 person

  8. 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

    Liked by 1 person

    1. 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.

      Like

  9. 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

    Liked by 1 person

  10. 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

    Liked by 1 person

  11. 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!!!

    Liked by 1 person

  12. 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

    Liked by 1 person

  13. 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.

    Liked by 1 person

  14. 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.

    Liked by 1 person

  15. 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.

    Liked by 1 person

  16. 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.

    Liked by 1 person

  17. 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.

    Liked by 1 person

  18. 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.

    Liked by 1 person

  19. 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

    Liked by 1 person

  20. 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

    Liked by 1 person

  21. 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’.

    Liked by 1 person

  22. 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.

    Liked by 1 person

  23. 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.

    Liked by 1 person

  24. 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.

    Liked by 1 person

  25. 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.

    Liked by 1 person

  26. 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.”

    Marketisation is thinning out previously thick institutions…

    Liked by 1 person

  27. 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!

    Liked by 1 person

  28. 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

    Liked by 2 people

  29. 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.

    Liked by 1 person

  30. 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

    Liked by 1 person

  31. 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.

    Liked by 1 person

  32. 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 .

    Liked by 1 person

  33. 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.”

    Liked by 1 person

  34. 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.

    Liked by 1 person

  35. 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.

    Liked by 1 person

  36. 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.

    Liked by 1 person

  37. 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.

    Liked by 1 person

  38. 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.

    Liked by 1 person

  39. 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!

    Liked by 1 person

  40. 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!

    Liked by 1 person

  41. 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.

    Liked by 1 person

    1. 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.

      Liked by 1 person

    2. 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.

      Liked by 1 person

  42. 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.

    Liked by 1 person

  43. 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

    Liked by 1 person

  44. 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.

    Liked by 1 person

  45. 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.

    Liked by 1 person

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