Christine Sinsky, MD, from the American Medical Association interviews Pamela Wible, MD, after her TEDMED talk. Watch periscope video here. Fully transcribed below:
Dr. Sinsky: This afternoon we’re here in Palm Springs, and I’m delighted to be here with Dr. Pamela Wible, who gave a terrific TED talk last night. I’m Dr. Christine Sinsky, the vice president of professional satisfaction at the AMA, and we’re here at TEDMED because it’s an important gathering of deep thinkers, of innovators, of practicing physicians. The AMA believes in bringing those key constituencies together. So Pamela, you really knocked it out of the park last night with your talk. It was really just terrific.
Dr. Wible: Thank you so much. It was really fun, amazingly fun to present a topic that’s so challenging.
Dr. Sinsky: I wanted to start out by telling you one of the things that are meaningful to me. That care of the patient requires care of the provider, and I could feel your passion last night around our need to be better as a medical community at caring for each other, at caring for our colleagues. I wonder if you’d like to start from there and move forward.
Dr. Wible: I think we really need more of a culture that is collegial and like a family, instead of a culture of competition. And that starts during premed and day one of medical school we could set the stage for more of a family atmosphere where we’re looking after each other like you would family members. I think that’s how it works in other high-stress professions like fire departments and police departments. People are really there for one another as supports.
Dr. Sinsky: So shoulder to shoulder, together. Picture for me, you are the dean of a medical school. You have the ability to help change that culture. What would you do?
Dr. Wible: Day one of medical school I would introduce the students to the campus and welcome them home. This is where you will be with your family for the next four years. You’ve jumped through enough hoops to get here, and we are here to support you. I would give my personal cell phone number to the students. I would have a panel discussion with some of our top leaders at the medical school who would share their personal struggles with despair and then triumph from professional liability cases, from deaths of their patients, from divorce, suicidal thinking and all of this so that we normalize the conversation of our human needs. And we can start to bond with each other beyond just the supratentorial lectures and multiple-choice tests.
Dr. Sinsky: You know, I was talking after your talk with one of my physician colleagues, and we were thinking about how we each felt in medical school and some of that impostor syndrome that I think all physicians feel — that we are isolated and alone, and no one else is feeling that way. Tell me more how this approach when you are the Dean can help to address that issue.
Dr. Wible: Right now students feel extremely isolated, and that just continues through our entire profession. We are in a culture that glorifies self-neglect. And so we end up working on our little islands, and we don’t ask for help because, of course, we are supposed to be the helpers. We are not supposed to be receiving help. And so if we can just break through this and really look after one another. Create a situation in which people do not feel individually defective. Once we can communicate that you cried yourself to sleep after the stillborn and so did I and we had the same reaction to that case, it just normalizes our human experience. And that’s what we need to do is start to have conversations like real people, like we are now without the stiff starched white coat.
Dr. Sinsky: Right. And the isolation behind the strong man kind of front. So last night you really spoke very much from the heart, about the extreme when we don’t care for each other. The stresses and lack of support can manifest in the most severe outcome — death by suicide. Can you talk a little bit about why that’s important and the extent of it, and move to solutions, things that we as a medical community can do to help our colleagues in pain.
Dr. Wible: It’s important because we are losing an entire medical school full of physicians every year to suicide, so hundreds of doctors. Both men I dated in medical school died by suicide. In my small town, we lost eight physicians to suicide, three within 18 months. So it’s a huge public health issue. More than one million Americans lose their physicians to suicide every year so we must take this seriously. If not for the individual, the public health implications of losing that many physicians when we already have a physician shortage. Right? So that’s one thing. What was the second part of the question?
Dr. Sinsky: I just want to clarify that a full medical school every year.
Dr. Wible: Yes. And that’s not even counting the medical students that die by suicide. And what disturbs me is we are not tracking any of this, and we could be tracking it because we know all the names of currently enrolled medical students and physicians in this country, so it shouldn’t be a mystery. We should have firm numbers. Some of this is not being tracked properly.
Dr. Sinsky: So who is doing it well? Who is addressing suicide prevention at the medical school level well? Or at the practicing physician level well? And if no one is what should we be doing?
Dr. Wible: Some schools like Saint Louis University and others are doing a pass-fail grading system, so there is not the tension about grades that creates that competitive environment. So if we just take the pressure off of these amazing people. Medical students are already in the top 1 percent of compassion, intelligence, and resilience in the country. How much more pressure do we need to put on these high-achieving people? Take the pressure off and let them enjoy the love of learning instead of just shoving all these multiple-choice tests that never end with medical minutiae that they are not going to use in the future. So take the pressure off and create an environment where there is peer networking and peer support groups. Schools should have a suicide helpline that the students man themselves. We learn to take blood pressure on each other. We are using each others’ bodies to learn how to do the physical exam. Why not let these medical students in their first and second year learn some of these skills to help each other emotionally? Have them on call from first and second year so they feel like they are doing something other than just reading their books. Actually helping each other.
Dr. Sinsky: So you are getting at one of those issues that makes physician suicide such a challenging problem, and that is for physicians there are barriers to getting mental health care and that probably starts in medical school. Getting mental health care from your boss or supervisors might be an issue and once we’re in practice. So what else can we do to reduce the barriers to getting help when we need professional help for depression that’s extreme, for example.
Dr. Wible: Well, one thing that I discovered when people call me is that medical students and physicians who do have extreme depression, anxiety, panic attacks that are occupationally induced were normal before medical school. Just listening to them on the phone helps. I am not giving them drugs. I am not their doctor. I’m just a friendly colleague on the phone. They feel so much better afterward. I continue to drive home the point that you’re not individually defective. This is a system defect. If more than 50 percent of a group of people develop a condition we call “burnout” — which is really a victim-blaming term — then it is really a system’s issue, not an individual issue. Once they realize that they are not individually defective, they feel so liberated, and they feel so understood. We should not wait until people are so far gone into psychotic depression that they need to go to a psychiatrist. The first day of medical school and as an ongoing continuum of care we can really listen to each other and be human with one another.
Dr. Sinsky: I want to make sure I caught this because I think this is a hugely important point. We need to think about the locus of responsibility for physician distress, for physician suicide, for burnout (if we us that term) in the external environment much more so that in the internal environment as a defect in the strength or the ability of that person. Did I understand you?
Dr. Wible: Yes. It is a bigger issue. It is not that the an individual was born with a resilience deficiency. You’re in the top 1 percent of resilience if you are in medical school so let’s honor your strength and capacity for learning and providing care for people. And one thing that I wanted to say since I think this is about creating your ideal clinic is that we should really teach to the personal statement, not just to all these multiple choice tests. People come in with a clear indication of what their soul’s purpose is and what their intention is and what they’d like to receive for their $300,000 of tuition and schools need to be teaching to these personal statements and digging them out of the file drawers and asking the students, “How are we doing getting you to your goals here? Are we doing well as a school?” There’s really only two types of practices that have emerged: relationship-driven or production-driven practices. What medical school seem to be doing now is driving everyone into assembly-line, production-driven practices that do not match what most people have written on their personal statements. So we need to go back and ask the students, “How are we doing? How can we do better?” and really help people live their dreams — because that IS the ultimate solution to suicide. When you are living your soul’s purpose, there’s no way that you want to take your life. It’s when you feel that’s been stolen from you [that life loses meaning].
Dr. Sinsky: So I want to ask the last question. What do you think organizations like your organization, the American Academy of Family Physicians, or the America College of Physicians, or the AMA can do to help reduce physician stress, reduce the risk of burnout, reduce the risk of suicide, and increase the likelihood that we’re practicing in an ideal practice?
Dr. Wible: I like to reference Maslow’s hierarchies of needs. During medical school, you are thrown down to the lowest rung of physiologic instability (not getting to eat, sleep, and all that stuff). What Maslow did is he studied people who were high achievers who were self-actualized, and that’s what we should do in medicine. Instead of talking about all the doom and gloom, start showcasing that doctors who have figured it out. Let’s have a panel of the happiest doctors in America so we can hear what they are doing and why they are so happy. Doctor means teacher. Medicine is an apprenticeship profession. We learn by modeling other people. So let’s start showcasing the people who are really having a good time, who’s patients love them, who are just really rocking it in medicine and that would be a really great way to learn how to do it right.
Dr. Sinsky: So this is not a set-up Pamela. You may not know, but part of the work we’re doing at the AMA is exactly that.
Dr. Wible: I really didn’t know that.
Dr. Sinsky: You didn’t know that. I guess we’ll close with this. We have put online a series of practice transformation resources to help to get back to our calling of relationship-based care. So that our physicians can spend the majority of their time on work that only physicians can do, relationship-building, and medical decision making. And they are all about creating an ideal work environment.
Dr. Wible: That’s lovely. That’s really great. I’m looking forward to seeing that.
Dr. Sinsky: Maybe we will call you in to be one of our authors. We also highlight places where people are doing a very good job. So, Pamela, I’d like to thank you so much. You’ve really inspired many, many people across the country with the work that you’ve been doing and the message you’ve been articulating.
Dr. Wible: Thank you so much. It is a joy to be here.
Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears. Watch her TEDx talk, How to Get Naked with Your Doctor. She hosts the physician retreat, Live Your Dream, to help her colleagues heal from grief and reclaim their lives and careers.