Are you at risk of dying at work? Know your Karōshi Line. Learn how to protect yourself from an early death in this podcast. Listen in . . .
“One of my best friends form medical school died a few years ago, 55 years old, excellent health, swam every day. Genius—musician, internist, bicycle designer. His name was Patrick Tekeli. His death affected me deeply. Mother found him dead. Suicide? Who knows; I call it Karōshi (過労死)—I’m sure you’re familiar with that, ‘excessive work death.’ But he made a great impression on me. I’ve already submitted my letter of resignation. In a few months I’ll be off the RVU treadmill. I may still work a few months a year, but I won’t be a slave anymore. Cheers, ~ Jack Foust MD”
In Japan working yourself to death is actually in the dictionary. Karōshi is a word that literally means overwork death. I’ve known many people who have died from overwork though I never knew there was a word for it. I’d further subdivide Karōshi into the acute and chronic varieties. After non-stop consecutive 32-hour shifts, this 30-year-old cardiologist Dr. Zhang nearly died from acute Karōshi. In this video he is seen coughing up more than 4 pints of blood.
Chronic overwork may be even more dangerous than acute Karōshi. Like a slow suicide, workers literally work themselves to their own graves. Most Karōshi deaths are due to strokes, heart attacks, or suicides. Karojishi is a suicide by depression or mental illness due to overwork.
In Japan, the “Karōshi line” is defined as a 60-hour work week (80 hours overtime per month based on the 40-hour work week). This line dictates the threshold over which a wrongful death lawsuit may be filed for government compensation.
As a reference resident physicians in US work 80+ hour work weeks (and some do 100 or more since the 80-hour work week cap remains unenforced by anything more than the honor system). In fact, the ACGME (accreditation body that oversees medical education in the US) is on the verge of lengthening shifts on new first year doctors to 28+ hours.
So I wonder how many hours a healthy human should actually work. What’s the optimal amount of time one can work and actually enjoy a normal lifespan with good health? I interviewed a random sampling of 14 people in the Pacific Northwest and the average response for a healthy workday: 5.8 hours.
Most folks felt 4-6 hours would give people enough time to exercise, eat well, care for their kids and enjoy their lives. On the high end, one guy said 10 hours if you’re job is great and 3 if your job sucks.
So what do you think? How many hours could you work each day without undermining your health or reducing your lifespan? Where’s your Karōshi line? Leave your response below.
Pamela Wible, M.D., is a family physician who reports on human rights violations in medicine. Most resident physicians work 28+ hour shifts. Many doctors die by Karojishi as discussed in this TEDMED talk Why doctors kill themselves. Dr. Wible is author of Physician Suicide Letters—Answered.
People pleasers are dangerous. They actually end up hurting people. Don’t be too nice anymore. Here’s how I recovered—and you can too! Listen in . . .
Check out the letter I just received:
Hi Pamela, I’m slowly making changes, but every day is a struggle. Part of my challenge is simply saying NO. I had a major breakthrough last week. My prior employer wants me to interview for another “job”…. I’m asking more questions before agreeing to go….like send me a job description/title and let me speak to someone about the current needs of the practice before making me drive over 3 hours on my vacation day!! Give me some specifics!! It’s been 7 days since I asked and I’ve yet to get a response. If you can’t answer simple questions then I don’t think I want to work for your organization! It sounds so dumb but it’s hard to say NO when I’ve been conditioned to be a YES person. It’s like they say jump and I say how high? It’s unfair and exhausting so I’m taking back control over my life NOW! ~ Erika
As doctors we’re used to being the straight-A valedictorian presidents of every club and organization. We’re people pleasers who submit to authority and we’re such do-gooder super-achievers that we tend to take on way more than we can handle. Saying no is a learned skill. Practice it now. In a mirror. With your kids, spouse, patients. To inspire you, here’s how I say no in my medical clinic: (feel free to steal these)
1) I say no to medication refills between appointments. More than 30% of calls to my clinic were related to prescription refills. No more! I say no to any patient or pharmacy requesting a refill outside of an office visit. I clearly state this in my office policy on my outgoing phone message. If a pharmacy still leaves a refill request on my phone line, I simply press delete (best feeling ever!).
2) I say no to angry men who yell during office visits. After divorcing my ex who had anger management issues, I’ve decided that anyone with an anger problem should seek help from a specialist in anger (not me). Don’t project your anger at your boss, wife, or mother onto me. I will not tolerate any loud, hostile men in my life.
3) I say no to charity care (yet I’ve never turned any patient away for lack of money in 12+ years). Medical care is not a passive experience. I expect patients to be actively engaged emotionally, physically, and financially. I give 110% to my patients and I expect an equal energy exchange in return. In the rare case that someone is truly unable to pay, I require that they donate their time to the community (soup kitchen, animal shelter, etc) just as I’ve donated my time to them.
4) I say no to assembly-line medicine. I didn’t invest decades of my life to become a caring and competent physician only to be held hostage in a big-box clinic seeing patients every 7-10 minutes. So I quit and opened my own ideal clinic where I see patients for 30-60 minutes (plus now I earn more too!).
Saying no has made my life awesome! Imagine if we all learned to say no. When large groups of people say no, governments, employers, and organizations respond. Plus the media loves it too!
Anytime you withdraw your participation or relationship with an organization or refuse to cooperate with a policy or job description, you are boycotting something. Boycotts create culture change—quickly. Think about the far-reaching impact of the bus boycott (when Rosa Parks said no she would not give up her seat). Withdrawing revenue (or revenue-generating employees) from a business in a capitalist culture is a sure way to get action.
When employees refuse to work as a form of organized protest, a boycott becomes a strike. In the UK this past year junior doctors were on strike due to unsafe/unfair working conditions. The senior doctors supported them and so did 54% of the general public. No patients died as a result. A well-planned strike creates culture change—even in medicine—and without harming patients. In the US, I don’t predict an all-out physician strike; however, each doctor who says no and refuses to participate in for-profit insurance, corrupt organizations, or medical institutions that violate the human rights of their workers is essentially a microstrike. In large numbers, microstrikes take down entire industries. Just watch.
People pleasers actually hurt people
By saying YES to corrupt organizations or employers that violate human rights of their employees, you are actually harming yourselves and others. The cycle of abuse in medicine is perpetuated by people pleasers who won’t say no. So congratulations! By saying no you are healing not only yourself. You are healing our wounded profession, your patients, and your community. Thank you!
Jon Azkue, a Chicago-area doctor, died by suicide just before completing his training. I first reported his death a few years ago. This is a follow-up story on his suicide. What really happened to Dr. Azkue? And why? In this podcast I break the silence on one doctor’s suicide.
Two years ago, on April 20, 2015, I first read the headline: Police: Doctor found dead near hospital in Berwyn. Immediately, I published an article on Dr. Azkue’s suicide. The next day, ABC news changed the title of the story to “Man found dead near hospital in Berwyn.” How does a dead doctor get demoted to a “man” found dead?
Here are the facts: On April 16, a maintenance worker calls police for a well-being check on a tenant, Dr. Jon Azkue, a 54-year-old physician employed at MacNeal Hospital. Police discover a suicide note and his decomposed body surrounded by helium tanks. Thinking they were propane tanks, police call the bomb squad and evacuate the four-story building which houses health professionals and medical businesses. Here’s how his neighbors and colleagues respond:
“I was actually going to get some baby food,” says Jemin George who evacuated the building with his family. “My daughter is in one of the vehicles and it’s been almost three hours since she’s had something to eat.”
“It’s an inconvenience for the patients,” claims Riz Ahmed, an employee at Chicagoland Retinal Consultants, a clinic located in the building. Clinic manager Anna Futya, is also frustrated by the inconvenience. “All the calls that are coming here—whether from patients or doctors—nobody is able to answer . . .
Wait, I thought this news story was about the doctor. The original headline clearly states: “Doctor found dead near hospital.” So why is the focus now on patient inconvenience? How did Dr. Azkue get scrubbed from his own story?
Dr. Azkue’s death is not only reported as an inconvenience to patients, he is treated as if he is guilty of a crime. There’s no sympathy, no sadness for the loss of a man who spent his life helping others. In the comments—amid jokes about terrorist plots and remarks about the selfishness of suicide—one doctor writes:
Wow. I’m appalled by the lack of sensitivity for the loss of life here. I myself am in residency and unless you live through it, you cannot begin to imagine the stress and sacrifices that we and our families endure—far greater than missed eye appointments. My condolences to his family and colleagues. The journalist and editor should be ashamed of the slant through which they allowed this ‘news’ to be delivered.
I’m compelled to discover the truth. Turns out Jon Azkue is a 1994 foreign medical graduate from Central University of Venezuela who was just a few months from completing his final year of internal medicine residency at MacNeal Hospital. Though he was a physician in Venezuela, his dream was to practice medicine in the Unites States. So what happened? Why would he kill himself just months before fulfilling his dream?
Physician suicide often leads to more questions than answers. In the U.S. we lose more than 400 physicians each year to suicide. Like most docs, Jon Azkue left a note. Why aren’t we analyzing these suicide notes for common themes to prevent more suicides? Why aren’t these suicides fully investigated? Why does it seem like nobody cares when a doctor dies by suicide?
Since the bomb squad left his apartment, we’ve heard nothing more about Dr. Azkue. We’ve heard nothing about lives he saved. This was his five minutes of fame. Nearly two years later and we still have no answers as to why, no investigation of his residency program (where I’ve been told other doctors have attempted and died by suicide). Sadly, my prediction that this doctor would be forgotten by the media and medical profession has come true. Are his years of dedication not even worth a plaque on a wall? Are doctors so disposable?
Since Dr. Azkue’s suicide, I’ve amassed hundreds of cases of doctor suicides. Plus a collection of “suspicious” deaths like the anesthesiologist found on the side of an interstate. “No foul play.” Docs found dead inside hospital call rooms. “No foul play.” Really? That’s it. No follow-up stories. Healthy docs dead. Prime of life. Top of their game. Chief of departments. Case closed. How can we solve a public health crisis by ignoring it?
Here’s the truth: One million Americans lose their doctors to suicide each year. Until we investigate why so many doctors are dying by suicide, we’ll continue to lose more doctors to suicide. Maybe if we took a sincere interest in Dr. Azkue’s death, we could prevent the next one.
Meanwhile the only public honoring of Dr. Azkue appears to be on my blog where co-workers share: I knew Dr Azkue and worked with him. Shame on the public for their insensitivity to this situation. Unless you know the whole story, people, think before you speak! You never know what someone else has gone through! Who are we to judge? May he rest in peace. I worked with him also and found him to be a kind doctor. He was very nice and very intelligent and it breaks my heart to see that he passed away.
Even Dr. Azkue’s son, Jon Mikel, reached out from Mexico to search for answers about the unusual circumstances surrounding his father’s death.
He was in fact fired on his third year of the residency (just a few months before graduating). The hospital didn´t tell us why exactly. He lost his visa status as a result and would have had to leave the country. We are from Venezuela, and its bad over there, really bad. That must have devastated him, as his dream, since I have memory, was to live and practice medicine in the states specially because he did his first two years of med school in Boston. He could not finish back then for financial reasons, so he went on to finish med school in Venezuela and was a doctor over there several years. After Chavez though, he committed himself to his dream of practicing medicine in the states. It took him years. We thought he had finally made it… By the way, my family went through his stuff, they found two job offers for when he finished in August as well as few good letters of recommendation. A relative spoke to the program director. We still don’t understand why he was fired. They told us it was a decision taken by a board, nothing that could be done there. But wouldn’t give us the why.
Now it’s 2017 and we still don’t know why. I do know of several residency programs that have a habit of firing final year residents just months form graduation. I’ve seen the victims vilified and careers destroyed. Any investigation into these programs? Not that I’m aware of.
In summary, a physician is sacrificed by his profession and the media chooses a patient inconvenience angle. Why? Wendy Eidman explains the unusual and callous reporting of this story:
So I used to be in television news (both an anchor and reporter); I can tell you exactly why this story was written the way it was. When the reporter got to the scene, she was not doing a human interest piece, which is the kind of story that you want to listen to. She covered a breaking news story, a situation that was unfolding — a possible explosive device in the building, the disruption of the residents’ lives, the consequences to the businesses involved, and the discovery of a victim in an apartment that had been rented to a physician, cause of death undetermined at the time of broadcast. It was appropriately done with the information that the reporter had at the time she had to go live. When I was in TV, it was station policy to not cover suicides in general unless the suicide had some consequence to the public — a person stepping in front of a train, causing the system to shut down for a time during rush hour, for example; in those cases, the story itself was the disruption of service to customers during rush hour. Management for my station felt that if they did allow coverage for suicides, the publicity might encourage suicidal people to go through with their plans. Since the reporter in this particular story had already gone live, it would have been good to follow up with the kind of story that you are envisioning once the coroner released the report that the doctor had indeed completed suicide. It would have been an awesome opportunity to do a series on the issue of physician suicide and the general state of medical care in America. I am going to hashtag the TV station so that they can read this comment and perhaps follow through during May ratings.
Physician suicide is a public health crisis, yet there has still been no follow-up story. No major media investigation. So I’ll continue to report on these suicides myself—and I will continue to honor our fallen physicians.
If you are a doctor, medical student, or health professional who is suffering, click here for help. If you want to know why so many doctors are dying by suicide, listen to this award-winning NPR interview.
In this podcast, I share insights from a doc who barely survived his suicide attempt plus simple ways to prevent the next suicide. Listen in. You may save a life.
Dear Pamela, I’ve never been so happy to fail at something in my life. Four weeks ago today I died. Cardiopulmonary arrest in jail. Why was I in jail? My wife alerted the police. Sheriff deputies were upset when I did not pull over to talk to them after overdosing. After boxing me in, they threw me from my truck into the slushy street and tased me. After charging me with a felony and two misdemeanors, they nearly provided the perfect assist to my suicide. Through a series of miracles I was brought back. I am missing four days of my life including three on life support, but I am alive. I have to repair almost every relationship I treasure from the betrayal of my weakness, a chore I will perform with as much love and patience as I can muster. I may never practice my specialty again, but I am alive. My family has a husband, father, son, and brother.
My wife once asked how we do it in the ER, to be there for everybody’s worst day and also for their best. My worst day was almost my last. Funny thing is I was as happy as I had ever been in my personal life. My decision to end it all was 100% work-related.
I had just lost a young girl in the ER a few weeks before. Influenza. I followed proper protocol, gave her a couple of treatments and she felt better so I discharged her home with appropriate warnings. Thirty hours later she came back, in respiratory arrest. She ended up on life support with family refusing to withdraw care. They, of course, blamed me. And, of course, complained.
My review was days later. While my employers were very sorry about the case and stated support for me, the result would likely lead to termination due to this incident and a few other cases that were trivial. I thanked them for their honesty. At first my wife and I talked about it, and I was fine. I could likely go back full time where I used to work. I returned to work that night sad, but comfortable with my likely outcome. When I got home in the early morning hours I was just sad. I cried for the girl and her family. I cried myself to sleep and woke up still sad.
There’s a saying we have in the emergency room when we witness trauma and death among the innocent: “A little piece of my soul died.” We’re never offered counseling and in the end you get the jaded emergency doctor who struggles to care. My psychologist says it wasn’t just the last girl. It was trauma after trauma after trauma.
Pretty sure I have PTSD from the Haiti rescue and recovery trip. From bloated bodies liquifying in the heat to starving kids begging in the street. Years later, walking into a Mexican hotel with similar tiles and stucco walls, I was overwhelmed by the smell of rotting flesh. Other times when opening a large perirectal abscess, I could smell dead bodies.
Tip of the iceberg. Horrible cases. A drug-related killing where a kid was bludgeoned to death with a baseball bat. Barely alive when his druggy friends dropped him in the ambulance bay. Child shot through the head when crack addict mom didn’t pay up. I had to assist taking clothes off siblings to obtain as evidence since they were covered in blood and brains. Shootings. Stabbings. We do this every day.
Yet I’ve never been depressed per se and never suicidal. I just snapped.
Sitting alone with my grief, I grabbed what I needed and drove up to the mountains. I thought my wife would be better off without me. I texted: “I’m so sorry. You deserve better. I have tried to be strong. I can’t take it any more. To have that girl die was too much. To have to face being terminated for it? I can’t go on. I’m sorry. I love you to the end of the world and back but after one final hurt, I can finally stop hurting you. You have your family and church to help you and you have your finances taken care of.”
I took a handful of pills with the final thoughts that my student loan debt would not pass on to my wife and at least she has my life insurance to take care of her. Then came the police cars. I don’t know why, except not wanting to talk to them or face my wife, I continued driving. I obeyed all traffic laws, never exceeded 22 mph and in no way endangered pedestrians or other motorists. At one point I pulled to the side, and multiple officers took cover and aimed guns at me. They wanted to know if I had guns, and I told them that they were in the vehicle and they could have them. I kept my hands visible as directed but refused to exit the truck because I did not want to talk to them. Ultimately, I was thrown from the truck, tasered, cuffed, and put in the back of a police car.
I requested to go to the hospital. I was surprised that they took me to jail. Seemed weird because I thought all suicidal people came to the hospital first. I started to get sick from the overdose. Sweating and nauseated and a little unstable on my feet. They had me sit in a holding cell in the booking area, and that’s the last I remember.
Of the next four days I have almost no memory. I am told I went into respiratory then cardiac arrest in the jail and they started CPR. I was finally transported to the hospital, where they got a pulse back. I was critically ill on ventilator support. My family was told I was going to die. Then my sweet daughter found what I took, and the appropriate meds were given. I improved. Couple days later I was off the vent and out of the ICU.
Almost every day, since that worst day, my wife just looks at me and repeats “I can’t believe it even happened!” The people I’ve told about this are utterly shocked. I have spoken with a few residents I used to teach and they can’t believe it. I can’t either. Could happen to any doctor. Seemingly without warning.
Nobody would have ever guessed this would happen to me.
I, however, have the residual aches and pains to prove it happened. As we try to heal, I spend my time reading scriptures, praying, and trying to get some level of fitness back (you might be surprised how hard a few days on life support can be on your body, not to mention chest compressions).
I am not sure of my return to the ER. Those few shifts worked after the girl died were awful. I was very unsure about everything. I could not make a decision on patients. If you can’t discharge a young patient with the flu, who can you discharge? Even though I did everything right, I still have trouble sleeping. I mourn for that family. Emergency medicine once defined me. I loved going to work every day. I think at one point I was a good doc who cared about his patients. Now I am just very anxious even thinking about going back to work.
Still, I’m trying to make sense of this. I’m certain of one thing—the Lord saved me for a reason! I am just horrified as I read through my chart of how very close I came (pH of 7.1, lactic acid of 15, heart failure, renal failure, elevated cardiac enzymes, and rhabdomyolysis).
Thank you again for all you do to educate and advocate for those that did not make it, and for helping to prevent even more suicides. Of course you can do anything you want with the story. I don’t want the attention drawn to me specifically, but I hope it can reach someone before it is too late. ~ Michael
My Dearest Love, Fiancé, Partner, and Best Friend,
I want you to know just how much I love you. I genuinely love you with every ounce of my body and soul. 🙂
But I worry about you. You’ve been beaten down. Your residency program doesn’t set you up to succeed. Every day, you’re overwhelmed by another ridiculous list of tasks. Constantly, relentlessly someone is seeking your attention. Then you get rushed, thrown out of a rhythm. Your superiors find fault in you, quick to criticize you for their own failure to demonstrate the path to success.
This evening, a phone call intended to bring you fresh optimism, renewal, hope…brought exactly the opposite. This doctor, whom you never met, shot down your dream clinic with a disturbing level of confidence. You tried to be polite, but I know the real you. I could FEEL your disappointment. Hoping to finally step off the treadmill, you were told that it’s impossible—an immature and idealistic dream—get over it!
It crushed me and made me cry for you.
I sit here knowing how much I love what I do as an infectious disease doc. I love the patients, the pathology, everything. It makes me happy and genuinely content with my life and career. And I know how much you love family medicine. How happy and excited you get when you talk about your country farmhouse clinic with the big garden. I imagine the wood stove crackling as a couple of cinnamon candles flicker beside you and your patient, each of you sitting on a love seat. You’re both sipping tea and just talking away like long-time friends.
Bimbo is curled up beside you while Puffy is lounging on your patient’s lap, licking a hand hoping to get a scratch on his head. Your patients love all the doggy kisses. Even the rough, gruff old men seem to soften a bit. They adore those dogs just as they do you, your kids, and me.
Now you hear the loud steps of your next patient, the diabetic contractor wearing his Timberland work boots. Remember? The one who never saw a doctor before you. You got his A1c down from 12.1 to 7.9. As always, he’s 15 minutes early so he plunks himself down into one of the wooden rocking chairs on our wrap-around, enclosed front porch with the potted flowers and gentle wind chimes. And he just rocks away until it’s his turn, as he does every time, rain or shine
This is your dream clinic. Do you see it in your mind’s eye? Do you hear the sounds? Smell the cinnamon candles? Can you feel the warmth of the stove and soft fabric of your love seat?
I so miss seeing that sparkle in your eyes. You are beyond exhausted. Lord KNOWS you have a good reason for it too. From my perspective, there’s not a damn thing you can do about it. Still you always give 100% each day so you can be the best physician, mother, fiancé, sister, and daughter.
Please…don’t let this broken system and poorly constructed program steal your dream. Don’t let physicians who are stuck in the mold, complacent, or afraid to challenge the norm discourage you. Forget them! Keep going, Every day you are one step closer to your dream.
I’m here for you. I’ll support you in every way I can. Please don’t forget that. Don’t pull away into your despair. If we have to build a shed out of donated scrap wood and furniture, plop it on the corner of the yard, with a kerosene lantern and a hand-painted sign that reads, “Your Family Doctor” then that’s what we’ll do.
I love you and can’t wait to see you in just one more day now that it’s past midnight!
Your fiancé, best friend, and colleague,
John
For expanded commentary on the love letter, download MP3 or listen in . . .
Pamela Wible, M.D., is a family physician who pioneered the first ideal clinic designed entirely by patients. She loves helping doctors open ideal clinics and live their dreams in medicine. Join our upcoming teleseminar to learn more.
