The Dark Side Awakens

Episode 2. I’m a surgeon. A simple one. I didn’t intend to trigger an outpouring of emotions. I didn’t plan on ever ‘going viral’. But since I wrote The Dark Side of Doctoring 4 days ago, I have had a huge amount of response. On top of the 150,000 hits on my article and the phone calls from several News Agencies, nurses in clinic and theatres have asked if I was OK. I was visited by the Head of ENT Department and the Head of the Division of Surgery. I was contacted by so many fellow doctors, nurses, clinicians from places as far away as Singapore, Sweden and South Africa. My email inbox has been flooded by many doctors, nurses, medical students and their partners who wrote about their own personal struggles in the institutions that they work in. Just take a peek at the comments section to that original article. Heart-breaking.

I have cried over so many of these personal stories. I am seeing many doctors, nurses and medical students in distress. I am seeing a generation of health care workers suffocated and strangulated by their circumstances. (If I haven’t replied, I will!) The conversations are already happening. Much of it online because they’re afraid to do it in real life.

The message from all these responses is clear, “I get you. I feel the same way too. I am not coping with this industrialisation of Medicine.” The article has triggered a universal emotion that many health care workers feel about the state of their vocation. I hope it has catalysed an awareness of this issue in medical institutions where you are.

Now that the Dark Side has Awoken, can we talk about this openly? If you are a Health Administrator, can you please listen to your Clinicians (that includes physiotherapists, audiologists, speech pathologists, Ambulance officers, etc) on the frontlines? We don’t need more programs, initiatives, directives, protocols, videos to watch or numbers to call. We know that those kind of help are available. We need workplace morale to be lifted. If you’re not going to start at the top, we are going to start from the bottom. Elevating workplace morale does not have to be expensive or prescriptive. It can be creative.

If you’re a health institution or health administrator or health leader in anyway, be courageous enough to tackle this elephant in your institution. Be courageous enough to champion this issue. You might save the reputation of your institutions, reduce sick leave, improve workplace environment and possibly save some lives.

I have some ideas about what we can do down at the trenches. We don’t need to halt the Industrialisation of Medicine. We can Humanise it. We can inject compassion into this Business of Medicine. We can regain some measure of control, support and meaning in Medicine. For the sake of our patients and the future generations of health care workers, can we please talk about simple, creative, compassionate human solutions to this problem?

Put up some ideas for discussion please.

This is Episode 2 of a Trilogy

Episode 1: The Dark Side of Doctoring

Episode 3: Restoring Hope and Humanity to Health Care

29 thoughts on “The Dark Side Awakens

  1. Steven John

    Hi Eric,

    I’ve worked more than 10 years as a consultant in the operating room at the coal front of a trauma hospital. We see everything from stabbings, gunshots, amputations and severe burns. Despite having failing infrastructure prone to flooding and water in the operating room, poor wiring that overloads when we hook up another fluid warmer and paint peeling from the walls, we get on with the job.

    A typical day may see 10-20 patients in excess of our capacity, waiting time for moderately critical surgical procedures. Naturally we bear the anger and upset from family about delays. Naturally we wonder if the delays in access are harming our patients.

    Never once in 10 years has anyone from health administration ever come down to see us. Not once in all of the weekends, nights, public holidays, christmas and easter breaks. Instead, we are usually shoved another form, another email.

    Health leadership should adopt a servant model – they should be assisting the front line staff, not making their job harder.

    A simple step to engagement would be to provide staff with food or something to drink. If staff don’t have more than 10 minutes to get a break, its ridiculous to expect them to spend 10 minutes in a queue at the hospital cafeteria.

    I’ve seen simple things like pizza and soft drink ordered for staff who are slammed with clinical work at other hospitals. It works wonders. It recognises them as humans, who succumb to tiredness and fatigue. It bolsters their spirits. It says that their work is important and valid. It says that the staff are important.

    1. Carolyn McIvor

      I am a gastroenterologist. For a happy 6 years I worked in a place where managers had a servant model. Their job, they stated, was to help doctors see patients and remove administrative barriers and interruptions. Coming back to Australia was a rude shock. Doctors are brow beaten by forms, intrusive or ignorant hospital processes and no one remotely focussed on what the patient needs. Rise up and question the processes that weigh you down! There is a better way!

      1. John

        Oh so true especially in Australia, the world master of bureaucracy! Out of control micromanagement without considering the consequences to clinical care, obvious ones most of the time let alone the “unintended” consequences. Who knew? Anyone who works on the frontline sees it straight away, and usually not even involved in the introduction of this new policy, guideline, protocol, pathway, blah blah – just another form with the same info that’s recorded elsewhere, in paper in another chart that’s always getting lost. Billions could be saved by going back to basics.

      2. katchak

        Well said Dr M. Can’t agree more.

  2. Jani V

    I agree we have to start somewhere. I remember the last day of my Psych clerkship, the PD had just come back from vacation and he decided to incorporate daily sessions to meditate and relax for students, residents, and attendings. 15 minutes every afternoon would be taken with no phones, no interruptions so that everyone could have that time to relax their body, mind and soul. I hope this series reaches some admins out there are changes can start being incorporated.

  3. Lisa

    Hi Eric,

    Good on you.

    I had to sit down with my intern recently, it was after hours, on my annual leave which had already started, but I needed to. My intern was inundated- with paperwork and nursing requests and pharmacist ‘please fix this to suit me’ requests, and radiology who wouldn’t order his images on time, the coroner’s inquest he has to write but doesn’t know where to start, the referrals he makes but the other teams don’t turn up. And then he was so busy dealing with everyone’s requests he was able to see the sick patients or check and interpret test results. I sat with him and discussed how bullshit medicine was, that he needs to tell people where to go at lunchtime so for half an hour he can read everyone’s bloods/XR results and then have another half hr for lunch. I taught him areas where I couldn’t care less if he wrote basic requests as long as they were ordered, that discharge summaries just needed relevant points and not essays and if anyone made it difficult for him that he needed to let us know so we could sort it out. All of this he needs to do so that he can spend 2hrs a day assisting sick patients and 30mins checking and interpreting test results. I told him that if anyone had a problem with that he could blame me. He needs to be a doctor to his patients, not a pen pusher to nurses, allied health, pharmacists, his registrars and god knows who else wants to push my intern to the brink of despair.

    I write 60+ letters a week about my patients and I’m a junior registrar. I have pulled hours to the point where my family think I’m dead because I can’t return calls, but I will not let you destroy my interns or my junior staff. If it takes one disgusted junior registrar to save these guys I will happily destroy my career to make sure these guys do well and feel good about themselves.

    So next time you request a doctor does some stupid bit of paperwork to fulfil some stupid rule that makes no sense why you would pull a doctor away from sick patients to do that – help them fill the bloody form out so all they have to do is sign at the end. If a junior doctor says no don’t try and go over their head to their registrars or to their consultants to ‘make them look bad’. Grow up. The amount of shit my interns have to deal with makes me sick.

    I never leave work until my interns have left. I send them home. I basically stand in between them and the nurses requesting they still do things after hours and say ‘well done, now go home’ the nurses dislike it, but I tell them to call the afterhours resident who is being paid. The nurses response ‘well it’s not like we get paid for working overtime either’. That’s not a response. I regularly as an intern worked and saw three to four different nursing shift swap overs. When doctors start their shifts in the morning- the same nurses are not there when they finish their shifts at night.

    The public should stick up for their doctors, thank them for being there. Please. They are dying because they have a thankless job.

    If you are a patient in a hospital- you want a doctor that has time to see you.

    Sincerely, a doctor who averages 6 work lunches a year and who missed Mothers Day recently to be there for other people’s families.

    1. DrEricLevi

      I get this. I totally get this.

    2. Bev RN

      Thank you for bringing attention to this issue. I completely agree that this is a problem that if unmanaged has an immediate and detrimental impact on practitioners and ultimately the quality of health care. I do, however, take exception to some of the comments made in the response posts. I believe that all health care professionals are experiencing this – it is not unique to physicians. Registered Nurses too have an over abundance of paperwork to complete, we miss breaks, stay overtime (paid and unpaid), sacrifice time with our families, and know that often we did not get everything completed that should have been and to the standard we would like. We too feel distress and remorse when we know patient care has not been delivered as it should be due to short staffing, fulfilling non-nursing requirements and policies developed by non-health care professionals. In addition we are now being told in many situations that you don’t need a RN education to provide care to very sick patients – that lesser educated practical nurses and nurses aides are sufficient. Despite an abundance of research that definitively ties positive patient outcomes and cost effective care delivery to RNs at point of care, and particularly to RNs prepared at a degree level, administrators are making staffing decisions to the contrary. This further puts stress on the few remaining RNs, the system and again, ultimately the patient and their family. RNs are educated to provide safe patient care, not to fill out forms to have physicians sign them. We work as a team. We are not physician secretaries or “handmaidens”. Your post identifies issues with nurses that are simply not their fault. If we are to tackle this issue and truly look for solutions we cannot have one provider blaming another. As a team we need to address the poor policies and practices being set with hospital administration.

      1. John

        Perhaps a worldwide rebellion could work? We all stop filling in unecessary forms from a certain date! What’s gonna happen? Sack everyone and have no medical care? Or get back to being caring, hands on, direct patient contacting, and EFFICIENT doctors and nurses!! The ball’s in out court, play it or lose … a simple and obvious solution I have thought about for years. Let’s do it!

    3. Naomi

      I am also appalled and always feel sorry for all the doctors who do long hours and get ridiculous requests to do more.
      As a fellow nurse in a busy tertiary hospital, I know we all cannot do our jobs without the other. I can assure you the ‘pen pushing’, ‘after hours ‘ requests, and the ‘going over the doctors head’ by nurses is not done just to annoy, intimidate, or inundate you or your colleagues. We too have ridiculous demands put on us, meaningless forms and audits to complete, all the while just trying to get a simple insulin order which hasn’t been done all day, so our sick patients sugar level doesn’t reach 20 for the 3rd reading in a row, and then being asked to explain why (an example).
      Yes, your hours are longer in general. But the demands are the same on nurses, pharmacists, radiology, physios, etc. No need to place blame on your fellow front line workers. We should all stick up for each other.
      Noone will ever understand what it’s like to have the pressures of a hospital environment unless you’ve worked in one. It’s like a different world.
      Things do need to change, I’m not sure how. I know we have to start speaking up when asked to do something like fill out a useless form that goes nowhere except for the hospital managers desk.
      We are ALL trying to meet ridiculous requests by others, with not enough time, resources, or care from management.
      All the while our goal is the same, trying to do the best we can, look after our patients well and with a little humanity.

    4. Zac

      Lisa, as another junior registrar, I’ve had the same experience as you. Thank you for taking the time to look out for your intern-they are often at a time in their career where they don’t know which requests to defer, how to prioritise some requests, how to differentiate which requests are just plain unnecessary (!), and are just so keen to be helpful to everyone. They also always feel like it’s their responsibility and find it hard to say no. What you (and many others I’m sure) are doing is an important start, but we should be able to help to our juniors, and enable change without sacrificing our careers.

    5. Marymwren

      Hear hear! I’m now long gone from hospital medicine and a single handed GP. During my hospital years I was often the only person on the team who made time to eat. It was simple, if I didn’t eat, no one got seen. As I moved up, I gave the interns my number to phone if they were stuck overnight with a patient or just needed to cry. Now as part of my practice I have 2 medical students with me for 18 weeks each in the year and I have a comprehensive list of advice that I give them before they leave, everything from eating regularly to not taking shit from management. Many have come back to me and said they passed it around to their classmates as well. We need to show our junior colleagues that we have their backs and demonstrate healthy ways to survive the training years, otherwise once they are out in their own practices/appointed as consultants, they’ll burn out before they even start.

  4. Shannon Tapia MD

    Thank you Dr. Levi for writing this. It was important for me, as a Geriatrician, to hear that even surgical specialties are becoming burned out with our system. I spend a lot of time wondering if the Medicare RVU system were not set up to prioritize procedures or patient volume and turnover (essentially if we Physicians, like lawyers, were paid for our time) if in fact more humanity would return to the field. The RVU system essentially does turn patients into commodities to either be poked and prodded or turned over in the assembly line……and now it’s turning Doctors into the same. Wouldn’t you prefer to be allowed to care? Wouldn’t you prefer to be able, as the physician, to decide which patients needed your attention and when the most? Even if it’s just a touch base phone call (I have found that a call from the doc can help far more than a call from even the best of nurses). In all of these proposed solutions, I almost never here anyone discussing root-cause analyses. There are a lot of band-aids out there. I think we may want to start pushing for salarying all physicians at an hourly rate that is adjusted to their years of training and expertise but whose minimum salary is fair. Far too long we have allowed non-physicians or competition to claim that to salary us it would make us lazy. This is complete poppycock. If you make it through med school and residency, you are not lazy! Point is, we would be guaranteed a living that we could pay our loans and support our families while simultaneously being able to bring humanity, love and care (all things that take TIME) back to our once-beloved profession. This would eliminate about 75% (that’s a total guess) of the admin and EMR junk because our notes would be relevant, not chart vomit meant to feed data systems, and we wouldn’t have to mess with ICD-9 and 10 codes.

    That got long fast! Obviously I’m a bit emotional about this topic. I’m fortunate that my husband is an Anesthesiologist and can support our family as I have just opted-out of medicare to start my own direct primary care all Geriatric practice. I may never make money, but it was that or stay miserable forever. And I owe it to my son, my husband, my patients, and my profession to do everything I can to not be miserable (because I can be quite unpleasant when I’m miserable).

    1. DrEricLevi

      Thank you for sharing.

  5. Yuki Aoyagi

    I am a physician working in New Zealand. I went to a medical school in Japan (my country of origin), trained in the U.S. (residency and fellowship), worked in Africa for two years teaching doctors there, and ended up moving here. I did not go back to the U.S. as I knew I could only work in a place where socialized medicine exists. Medical care in New Zealand is free. We do not have to deal with billings. Litigation is extremely rare as complications of medical care are compensated by the government. When I moved here, I was surprised to find that more than 50% of the ED physicians at our hospital were from the U.S.. The health system here is at least governed by sanity, but not by industry. We do not have to care about our patient’s insurance status and provide the same level of care to each individual. I call it ethical and that is how we should be as physicians.

    1. John

      Too true, NZ is a beacon all others should follow.
      Wealth is not health, money should not be a factor in fair provision of medical services.

  6. R m bruce

    Hi Eric. I am a g.p. But I was an ED reg, and I dropped out for eight years when I had twins as I wanted to breastfeed and couldnt hack the B.S. you get as a trainee female.
    I was given a weekend off to get married, after working 60-80 hr weeks all year for them in ED. I watched consultants have mental breakdowns, and we picked up their hours. Ive spoken to parents with their dead child between us, I’ve called the police for men with loaded weapons, I’ve seen in my two decades colleagues I know are using opiates to cope. I am part of administration now too b/c I stood for election on our local hospital. Still astounds me the niavity of the managers. No concept.

    Its killing us. I thought it was just the weak ones when I was younger but I’m 50 soon, and the Pressure is beyond human endurance. Keep speaking. Vulnerability is a badge of humanity. To no longer feel isnt human.

    I do have some ideas. My ideas are simple and I think they will work, because they are how I’ve coped. I have a v v high BS detector and if its BS I write that in capital letters and send it back to the administrator that originated it. With references to the medical jounal of relevance.

    I also surf and ski, and book these in every year.

    And I guard my brain. No opiates, no top shelf, no recr drugs, no god, no woo. All darkness there. Just maximum wilderness and holidays w the kids and friends. …. we are an ancient, collegial profession, and we need back what we have lost in the avalanche of BS from nocters – not doctors.

    Kia kaha.

  7. Leanne Best

    Dr Eric Levi. Thank you, may your words
    make a difference. Leanne Best, Charge Nurse floor coordinator, Starship Children’s Hospital, Auckland, New Zealand

    1. DrEricLevi

      Leanne, I will see you in the not too distant future. And you will teach me how to be a good surgeon.

    2. DrEricLevi

      I’ll see you in the not so distant future, Leanne. You can teach me how to be a good surgeon.

  8. Eliza

    Fantastic blog eric,

  9. Merv Atkinson

    Not that I ever expect hospital adminstrators to read this, but if they could heed just 1 point:
    Stop engaging external admin and finance ‘experts’ at vast expense and instead spend the time to ask the front line staff wjat is the worst problem and how can it be ameliorated. Staff know the job and the routine. They choose to work for the patient. They are the experts. How about letting them have a say?

    1. DrEricLevi


  10. […] The dark side of doctoring. A must read blog post by¬†Eric Levi¬†reacting to yet another recent doct...
  11. Tara Chinn CRNA

    Dr Levi,
    I am a Nurse Anesthetist in the United States. I have been in practice for 28 years. What I have witnessed as a practitioner is so eloquently stated in your writing. I did love the practice of anesthesia. Now I barely have time to greet a patient. I am driven by rules paradigms and flow charts. My medicines are restricted because in the US the drugs are not produced in great quantities so I’m short on drugs vital to my job. My charts are analyzed and I’m to correct them promptly. My conversations and behavior are monitored at all times by everyone I work with. If anyone takes offense I am not talked to; I am written up with no explanation on my part being heard. No exceptions are made for any rule. I cannot wear certain clothing items due to the AORN and JACHO mandates which are not all backed by science. It has become a fear driven paranoid work environment. The patients have changed as well. They were grateful when I started practice. Now they are not and want to direct what drugs I give or sue me. The administration is like a huge uncaring hive of machines which are only data driven. If you can change this soul destroying system I would practice a little longer .

  12. Ivy Bolas

    I get this. Up to four years ago, I was a surgeon. Work-life balance was in perfect equilibrium: Work=Life. Then, my child arrived. It was either her or working in the system that doesn’t care about the those giving the care, a system that squeeze every goodwill out of doctors, a system that makes monsters of those who have been in it for long enough and back-stabbing gutter-snipes of the young ones who are on the the make. I do miss my job and we need the money, so I will return, but on my own terms because I am not sacrificing my child’s relationship with me.

  13. paulmackey

    Thanks Dr Levi and the repliers for getting it out there. It is a hard but also rewarding job that we do. The two kinda need to go hand in hand for it to be so. As you pointed out, the job loses its meaning when we are prevented from doing it. As I say to residents and medical students, “the medicine is the easy/worthwhile/rewarding bit. It’s the system/BS/forms [insert not patient relevant item here] that gets you down”. As another blogger put it so eloquently, “The quality of the care you receive is directly proportional to the amount of time your doctor/nurse/pharmacist is thinking about you”. Thus anything unnecessary that distracts me from thinking about the patient raises my ire and will get punted if it is within my purvue to do so. In the midst of all this outpouring it is important to have solutions. We (personally) have been fortunate to live in supportive though under-resourced rural communities. I have been able to switch off to get to a reasonable number of family/personal events. Conversely I have helped take up the slack when someone else needed it. I have made the point of sitting on various clinical committees so I could apply the brakes when an administrative distraction was being proposed. Remaining engaged at this level is imperative if we wish to retain some control. If we walk away from the meetings we give up
    control. The only ones who will look after us are our own and we need to support each other to the limits of our own abilities/wellness/time. Finally we need to remember that, if we are suffering, then our patients are suffering (maybe more). Keep it up.
    Dr Paul Mackey @auscandoc.

  14. […] Episode 2: The Dark Side Awakens […]...

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