“Medical school is a great anti-mentorship program. You meet a lot of doctors you’d never want to become.” That’s what med students keep telling me.
Mentorless medical students?
I had no idea. Until students started shadowing me. Many also volunteer at hospice and free clinics. I asked one gal, “You must meet a lot of wonderful doctors there. Right?”
“Not really,” she said, “Doctors are on automatic pilot as they try to navigate through a staggeringly high volume of patients. It’s so disheartening. And what’s worse, everyone I speak with says, ‘That’s just the way it is. It is too expensive, difficult, and risky to go into private practice anymore. You can’t be a solo doctor in this day and age.’ After meeting you, I know there is another way.”
“You haven’t worked with solo docs?”
“No. I haven’t met anyone else who has escaped our broken system to practice medicine as it should be practiced—on a personal and human level. I was worried that I was having childish delusions of grandeur by thinking I could actually practice medicine in such a way in today’s climate. I worried I’d go through med school and residency only to find that in the end there was no refuge from our inhumane health care system. I’m here because there are no tools or mentors to help me be the doctor I’d like to be.”
Medicine is an apprenticeship profession. We learn by watching doctors around us. Sadly, many aren’t happy. Most docs I meet have been victimized for years. Many think they’ve got “burnout,” but physician burnout is really physician abuse. Hint: No amount of deep breathing, meditation, yoga, resilience training will make your crappy assembly-line job joyful. Cut your losses, get a real mentor, and move on.
So how do you find a mentor?
Look for doctors who are doing what you want to be doing and hang out with them—now! If you want to be a happy doctor treating real patients, your mentor should be a happy doctor who is treating real patients. If you take business advice from cynical doctors who are depressed—you’ll be getting career advice from depressed cynics, if that’s what you want. Warning: if they’re not happy successful doctors seeing real live patients, how can they help you become a happy REAL doctor?
The right mentors are practicing medicine the way you want to practice medicine. Beware: there are many physician gurus, authors, speakers and burnout specialists out there who are no longer practicing medicine—because they “burned out.” Would you choose a divorced marriage therapist who has never had a successful marriage? Avoid advice from people who have never done what you plan to do.
Pamela Wible, M.D., founded the Ideal Medical Care Movement. She has been awarded the 2015 Women Leader in Medicine by the American Medical Student Association for her inspiring contributions to medicine. Contact Dr. Wible. She loves to hear from med students and docs.
Physician burnout is the latest trend among doctors. There are books, workshops, even special breathing exercises for physician burnout. Suddenly every other doctor I meet has burnout. And half of all med students have burnout before they graduate! WTF.
We enter medicine as inspired, intelligent, compassionate humanitarians. Soon we’re cynical and exhausted. How did all these amazing people get so screwed up so fast? ATTENTION medical students and doctors: It’s NOT your fault.
Burnout is physical and mental collapse caused by overwork.
So why are we blaming the victims?
The fact is medical students and physicians are collapsing because they are suffering from acute on chronic abuse. At some medical schools, 100% of students report abuse.
And it doesn’t get better. Physicians are overworked and overwhelmed with bureaucratic B.S. during most of their careers. They are trapped in assembly-line big-box clinics where they are treated like factory workers and berated for not seeing enough patients per day. Some experience human rights abuses in our nation’s hospitals. This doctor worked 7 days in a row with almost no sleep!
Think this is unusual? It’s not.
Physicians all over the nation are suffering mistreatment.
Folks, this is NOT health care.
The health care cycle of abuse starts on day one of medical school. Abused medical students become abused doctors who may one day end up abusing patients. Wait! We wanted to help people, not harm them.
ATTENTION Medical Students and Doctors:
If any of this sounds familiar, your diagnosis isn’t burnout, it’s abuse. That’s right. If you’ve suffered mistreatment or harm at work or school, YOU are a victim of abuse.
How do you know if you’re being mistreated? 1) You don’t get lunch or bathroom breaks. 2) You are forced to work multiple-day shifts. 3) You are not allowed to sleep. 4) You are forced to see unsafe numbers of patients. 5) You can never seem to find “work-life balance.” 6) You are threatened verbally, financially—even physically. 7) You are bullied. 8) And if you ask for help, you’re called a slacker or worse.
If any of this sounds familiar, it’s NOT YOUR FAULT.
YOU ARE A VICTIM OF ABUSE.
So what should you do? Sign up for a resiliency training? Meditate? Take deep breaths? Your goal should NOT be to cope with abuse. Your goal should be to STOP it.
Physician burnout is a diagnosis that blames the victim, not the perpetrator. In fact, the term physician burnout IS physician abuse. It implies that you are to blame, not the system and perpetrators of the mistreatment.
To prevent burnout, health care institutions may offer resiliency classes to train doctors to prioritize self-care and manage their emotions. WARNING: You can not meditate your way out of abuse. You can not take enough deep breaths in a year to end your abuse.
WHAT YOU MUST DO: If you are being abused, YOU MUST LEAVE YOUR ABUSER. I know it’s scary. But you are not alone. Need help with your escape route? Call me! I escaped. You can too.
Pamela Wible, M.D., founded the Ideal Medical Care Movement. When not treating patients, she devotes her life to helping her colleagues find happiness and joy in their own ideal clinics. Ya know, so patients can finally get the care they deserve! Image by Pamela Wible. Videos by GeVe.
This week TEDMED announced, Pamela Wible, M.D., Physicians’ Guardian Angel, as a speaker at this year’s event in Palm Springs, California. She will speak on physician suicide.
Dr. Pamela Wible was interviewed on NPR station KPLU in Seattle on physician suicide and her interview won a national award! Second place, Division A, for Best Interview from PRNDI (Public Radio News Directors, Inc.) Listen in here. Full transcript of her interview below:
GS: You’re listening to Sound Effect from KPLU. I’m Gabriel Spitzer and this is the kind of letter that Pamela Wible gets.
PW: “Dear Pamela, An anatomy professor did in fact inform us that we would commit suicide at a higher than average rate and informed us from the lectern how to accomplish it successfully. Considered following the instructions on 3 occasions—most recently when a 4 year old I had in the hospital died.”
GS: Okay, so this is a letter from a fellow doctor—a doctor who’s grappling with thoughts of suicide. Physicians are in the business of saving lives, but they have one of the highest suicide rates of any profession. An estimated 400 doctors a year take their own lives. Pamela Wible is a physician in Eugene, Oregon, and she’s devoted a big part of her career to helping doctors cope with thoughts of suicide. As you can probably tell this is a tough subject that’s not going to be appropriate for all listeners. And this interview in particular gets pretty heavy. It’s about 10 minutes long. When I talked with Wible, she told me about the moment she realized how big a problem physician suicide is.
PW: I was sitting at the memorial service for the third physician that we lost in our small town in just over a year. And I sat there in the second row of his memorial service, and I just started counting the suspicious deaths of doctors and I realized I had quite a number of them, including both men that I dated in medical school.
GS: What is it about the profession that makes suicide a particular risk?
PW: Well, we have kind of an antiquated medical education model that’s based on the, I would say, tough-it-up, suck-it-up, don’t cry, feelings aren’t welcomed here, do your job, do it efficiently—almost a militaristic model of medical training and that’s very dehumanizing to the students. And a lot of medical students actually graduate with PTSD. So it’s a traumatic educational process and I think that’s the root cause of much of this.
GS: Oh, that’s interesting. So it’s really about the paradigm that’s kind of drummed into them in med school and in training?
PW: Right. Because when you compare the mental health of medical students at the beginning of training, they come in with their mental health on par with or greater than their peers. And something happens during medical training that disables them essentially.
GS: Can you think of an example from your own training that demonstrates that way in which you feel it dehumanized.
PW: Well, besides the obvious sleep deprivation and the massive amount of material that we’re supposed to learn, in my particular program we had to do dog labs which meant that every 4 students were assigned to one dog that used to be a pet and we were supposed to kill it to learn very simple physiologic techniques that could have been learned in other ways. This is absolutely a dehumanizing process that I protested and was able to get exempted from. In fact, they didn’t even refer to this as an experiment. The physiology professor referred to this as an experience—in which there was no alternative. And they actually made fun of me. The dean told me I had, “Bambi Syndrome.”
GS: Do doctors get care when they need it? I mean mental health care. Considering that doctors are dispensing care and counseling patients all the time, you’d think that they would know exactly what they need and how to get it.
PW: No. Absolutely not. In fact, we are not “allowed” to seek mental health care for fear of losing our license. On our licensing applications there is a question that is actually in the same area as the questions about criminality, and DUIs, and felonies. In there, in that section, there’s a question about if you have ever sought mental health care. And if you check yes, you will have to probably meet with the Board in person to describe why you did that. I’ve known a physician, in my town actually in Oregon, who was delayed in getting her license by 6 months because she checked that box being completely honest and why she checked it is she sought counseling during a divorce. Ya know, everyone is depressed during a divorce. She had to pull her records which that counselor had since retired. They made her go get evaluated by another counselor for her mental health before they would allow her an Oregon medical license.
GB: So that has a chilling effect, huh?
PW: It has a chilling effect because, ya know, honestly I have a friend who is a psychiatrist—she’s an excellent psychiatrist—and she actually drives 200 miles out of town, uses a fake name, and pays cash to get mental health care. How would you like that? In order to be off-the-grid and not be tracked by the medical boards.
GS: Oh, wow.
PW: The other thing I hear from medical students and physicians all they time is that they actually are jealous of their dying patients in hospice and they wish that they could jump in bed and be the one with cancer so they could get some down time and some rest.
GS: That is so shocking and it’s so different than they lay public perception of doctors. That doctors are either heroic, mission-driven, ya know, saintly people or, ya know, that doctors are businesspeople or whatever. What you’re describing is really alien to folks who aren’t close to the profession, I think.
PW: Physicians are not allowed to really be vulnerable—and to share what’s really going on. So they put on the white starched coat, and smile, and have their bow tie—and nobody really knows what’s going on under that coat.
GS: So you have chosen to tackle this in some very particular ways including these retreats that you bring health care professionals on. Can you talk about those? What happens on them?
PW: These whole things began as just business strategy retreats to try to help physicians who want to open independent practices. But interestingly, on that day that I went to this gentleman’s memorial, that evening I had a retreat. And I showed up and I had fallen into this physician suicide topic in such a bizarre way and I just thought I would check in with the people attending the retreat and I opened the retreat by asking, “How many of you have lost a colleague to suicide?” And everyone’s hand was raised. And then I asked, “Well, how many of you have considered suicide? And every single hand remained up, including mine, except for the one female nurse practitioner.
GS: Did that change the nature of those retreats then?
PW: Well, I started to realize that a lot of people came to the retreats for emotional healing and that was really was in the way of them starting their independent practices. Emotional healing is required before we can really be the doctors that we dreamed of being.
GS: So when you’re together in those settings, how to set out about trying to help people?
PW: Well, I think a lot of it is just having these healers off-the-grid. There’s no cell phone, no Internet service. I’ve got 40 to 50 doctors in a lodge room on 150 acres in the mountains of Oregon. And they literally are just finally willing to share the truth about their experiences in medicine and so there’s a lot of crying, there’s a lot of hugging and a lot of validation. And I think people for the first time feel that they’re not defective. The system is defective and they’ve been abused. The other thing that’s so beautiful is actually because we were wounded collectively, I do feel like the treatment for physicians is collective. Meaning pulling off the “weak ones” on the periphery and throwing them into a psychiatrist’s office isn’t the best way to deal with our collective wounds. So I think when you can get healers together they naturally heal one another. It’s a really beautiful thing to witness.
GS: So you said that when you asked that question about how many people in the room had considered suicide and everyone’s hand went up including yours. What do you want to say about your own struggles with suicidal thoughts?
PW: I want to say that I came into medicine like most people as an idealistic humanitarian that just wanted to help people and the reason why I developed these suicidal thoughts . . . I mean I did get into some major depression in my first year of medical school completely related to those dog labs and watching the dehumanization process of my classmates which was just brutal. But then once I got into [practicing] medicine, ya know you’re always thinking it’s going to be better on the other side, wait until you graduate. But I was much like everyone else in the country funneled into these assembly-line medical jobs which are not the definition of healing, Seven-minute office visits where you’re just feeling that you smacked Band-Aides all over people is not at all health care and so I got depressed and suicidal because I felt that I could not believe I invested 24 years of education, all this time and energy, into a profession that I love, and when you are stuck in a system that does not allow you to be a healer, it’s a absolute assault on your soul. And so that’s where I was—the dark night of the soul.
GS: What helped you emerge from that?
PW: I had an epiphany that if the patients are miserable and I’m miserable and I’m looking at my colleagues and they look miserable, even though, ya know, they’re faking it sometimes and putting on these smiles. I just decided, you know what, I’m going to turn this over to my community. I’m going to lead a town hall meeting and I’m going to ask the end-user—the patient—to design their ideal practice and to write my job description and I’m going to work for them. And I’ve been so happy doing this now for 10 years in what I call, an Ideal Medical Clinic designed by the patient.
GS: Do you see any signs that this is getting any better? Is the training . . .?
PW: Yes! Definitely. Because we’re talking about it. They fear of speaking about the trauma that we experience as medical students and physicians is dissipating so that we’re more able to have this open and with the Internet kind of conversation. And the fact that we are no longer hiding all these bodies and all the data is the big first step. If you think about it, to use a medical analogy, there’s no way you’re going to solve someone’s medical problem until you have the correct diagnosis. Where would we be if we were afraid to say Ebola out loud or HIV? We would be nowhere. And so we’ve got to be able to say physician suicide out loud. And the next question after people recognize that this is a crisis is “why?” And when people start asking why, then we start solving it.
GS: Well, Dr. Pamela Wible is a family physician in Eugene, Oregon and she joined us from the studios of KLCC. She works with doctors in the Northwest and all over the place on suicide prevention. Thank you so much for being on Sound Effect.
Pamela Wible, M.D., offers teleseminars and retreats to help her colleagues heal from their trauma & live their dreams in medicine. Private retreats available virtually and on-site in Oregon.
“It may sound silly, but what are the bare-bones requirements to practice medicine? I plan to launch a small, low-overhead, cash-only practice, but I’m having difficulty finding a clinic or physician to model.”
No surprise that this doc who called me today is having trouble finding a role model. Most physicians work at high-overhead jobs they hate. Happy docs are in short supply.
I’m an expert on bare-bones medical practices. In 2005, I wanted to know how low I could go and still operate a real clinic in America. My start up costs for year one? Less than $3000. I actually launched on day one for only $627. Here’s how I did it delivered in a Las Vegas keynote. I’ve learned a lot of savings strategies since 2005. I’ve helped hundreds of docs launch successful ideal clinics (and one friend actually launched for $85!) So I’m pretty sure you can do better than me. Here are the basics.
Bare-bones requirements: A state medical license. For cash-only, opt out of Medicare. That’s really it. Optional: If you want hospital privileges or to be a “preferred provider” who’s in-network with insurance plans, complete credentialing forms and sign contracts. Done. Want to be out-of-network like me? Skip it all and you can still take insurance. Do NOT make this complicated guys!
Bare-bones start-up costs: An office (mine: $280/mo in 2005, now $425/mo in 2015). Utilities and Internet (included in my rent). Cell phone (mine $68/mo). Malpractice is cheap(mine $1230 first year, $1978 now, divided/billed quarterly). Laptop (I owned one, you probably own one too). Furniture (chairs, table, decor from Goodwill for $200). Exam table (free to $1500, I splurged at $795, ignore if you’re a psychiatrist). Premises liability insurance (included in most malpractice policies). Supplies (KY, gloves, scalpels, gowns for $300). File for LLC if you want ($50 most states).
There’s tons of FREE stuff for clinic start-up including free medical equipment from retiring docs/ hospital overstock. Seriously, you can get pretty much anything from morgue tables to NICU incubators for free! I created a free EMR on my laptop. You can get free business cards online. I use a free e-billing clearinghouse (officeally.com) to submit claims—and I get paid in a few weeks. Easy! Labs provide free supplies (Pap collection kits, urinalysis containers). Want more free stuff? Just Google “Free ____” and fill in the blank.
Let’s assume you have your medical license and DEA from your last job. You already have a cell phone and a laptop like most Americans. So if you’re opening a small, low-overhead, cash-only practice, with no staff or on-site lab tests as a sole proprietor, you can do it bare bones for less than $3,000. Even less than $2000. Want to really go bare? Skip malpractice insurance and take off $1000+ per year. Take another $1000 off if you’re a psychiatrist since the only equipment you need is two chairs and your brain.
Pamela Wible, M.D., is a physician business strategist who founded the Ideal Medical Care Movement. She was awarded the 2015 Women Leader in Medicine for her pioneering work in medical care delivery and medical student/physician suicide prevention. Photo by GeVe.
I’m a physician entrepreneur. In 1998, I opened my first clinic. My malpractice: $500/year. Then I tried life as an employed physician. Hated it. So in 2005, I opened my ideal clinic. Best. Job. Ever. My malpractice: $1230/year. Want low premiums? Here’s how I did it.
A quick tutorial. New malpractice policies mature over 5 years. So the first 4 years you’re getting a deal. My insurer discounts: year 1 = 64%, 2 = 44%, 3 = 23%, 4 = 11%. In 2005 a mature premium for a family doc here in Oregon was $8800, so at $1230 I got 86% off! Ten years later, my 2015 mature premium is $10,326, but I’m still paying a tiny fraction of that. Here’s how.
Ask for discounts! My insurer offers: board certification = 2.5%, loss prevention CME = 7.5%, and part-time discounts (0.70 FTE = 30%, 0.50 FTE = 50%, 0.25 FTE = 75%). Same policy more than 5 years? Take another 10% off. The great news—discounts are cumulative!
Next step. Always inquire about state credits. Practice in rural Oregon? The state will reimburse your carrier up to 40%. Yep! Take off another 40%. This is in addition to the $5000 state income tax credit for rural docs. Seem too good to be true? I called my insurer to confirm. On the low end of their 2015 Oregon annual premiums is internal medicine at $7,169, psychiatry at $7,275 and peds at $9,912. High end is OB/gyn at $77,233 and neurosurgery at $86,360.
Let’s do some quick math. Say you open a part-time solo practice as a board-certified internist in rural Oregon and you take all applicable discounts and the 40% state reimbursement credit. Your annual malpractice premium? $698. Take your $5000 income tax credit and you actually GET PAID $4302!
A part-time brain surgeon in rural Oregon? Same scenario with all discounts and credits, you pay only $3,412.
As a physician business strategist, I’m always teaching med students and docs how to save money and avoid poor practice decisions. Before signing with an employer or malpractice carrier, look for exclusions (some exclude defense for alleged sexual abuse or board actions). And know how you’ll cover your tail!
To cover your tail, you need tail insurance. For the novice, there are 2 types of malpractice policies: occurrence and claims-made. The less-common occurrence policy protects you from a covered incident occurring during the policy period, regardless of when the claim is filed. Most policies are claims-made and they cover you only when BOTH the incident and claim happen when your policy is in force. So if you move to a new job and afterward a claim is made at your old job during the time you were “covered,” you’re not covered! Tail insurance allows a physician to extend coverage after termination of a claims-made policy. For a fee. Usually 1.5 times your premium.
Attention! DO NOT EVER sign an employment contract without addressing your tail. When I left one job, I got billed 18K for tail! So at my last job, I negotiated my way out of the standard doctor-pays-tail contract. Then I left. They paid. Happy ending 🙂
Most policies cover 1 million per incident and 3 million aggregate annually. High-risk specialties may purchase additional coverage—up to to 5 million/10 million.
By the way, premiums vary wildly between specialties and regions.
Per ISMIE Mutual Illinois, here’s the mature rate for:
A Chicago family doc: $33,788 (> 3x Oregon).
A Chicago internist: $39,444 (> 5.5x Oregon).
A Chicago neurosurgeon: $239,204 (nearly 3x Oregon).
That’s for 1 million/3 million coverage.
Want a 2 million/4 million policy? That’s $362,396.
Rural Oregon is such a beautiful place for brain surgery.
Want to relocate? No problem. Your tail is $543,594.
Want more business strategies? Join our teleseminar!
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Pamela Wible, M.D., founded the Ideal Medical Care Movement and has been awarded the 2015 Women Leader in Medicine. Dr. Wible teaches medical students and physicians the business skills they need to succeed at her biannual physician retreats. Premed and med students encouraged to attend! (You won’t learn this stuff is med school.) Photo by GeVe.
