Why I encourage patients to fire me →

Fire Doctor

Not all relationships work out.

My prescription: if a relationship isn’t working, end it. Now.

Recently an insurance plan told me they were sending a nurse to my office for a chart review that would take 3 hours. After 24 years of education, state licensure, board certification, and over 50 hours of continuing medical education each year, I’m not trusted to provide Pap smears or treat sinusitis without monitoring. OMG. I’m a solo doc. No staff. I can’t spend 3 hours being micromanaged by a nurse. I’m busy treating patients—and helping suicidal doctors struggling with the same insurance B.S. My solution: terminate contracts with all insurance companies.

Then—I gave my patients the option of terminating me. I even wrote the “Dear John” letter for them.

Love me? Love me not?

Dear Patient,

You may have received a letter from your insurance company indicating that I’m no longer an in-network provider with your health plan and that you will “need” to select a new participating provider in order to receive your plan’s benefits at the highest level. Is this true?

The truth is I will be out-of-network with all insurance companies as of June 1, 2015. This means that you may be responsible for a higher percentage of your office visit (call your plan for specifics). Ten years ago, I opened this clinic so that I could be a real doctor. Many insurance plans are making rather burdensome demands on in-network “preferred providers” so I’ve chosen to preserve my sanity—and still care for you. At this time, I will continue to submit your claims and expect nothing significant to change—other than your copay.

Let me assure you that I will continue to be your doctor regardless of your insurance plan—even if you have no insurance. I’m honored that you have chosen me to be your doctor and my commitment to you and to our relationship is lifelong. Since I never plan to retire, I will be here for you—until one of us dies. As in any relationship, it’s good to “renew our vows” with one another. I’m writing to find out if you wish to continue having me as your doctor—or not. If you value having a lifelong relationship with a doctor off the assembly line and believe my care is worth more than a $20 copay, I encourage you to say “yes.” 🙂

Please respond to this email with a “yes” or “no.”

Sincerely,

~ Pamela

P.S. If you’re uninsured, ignore the first two paragraphs. I welcome you, as always, with open arms. Please also indicate your intention to continue under my care.

And the results are in . . . 

“YES! Abby and i have been down that road of Doctors that frankly wanna push pills and don’t care, we love you!”

“I am not interested and have asked to stop getting emails . . . I have had a new provider for over a year . . .”

“Uninsured, would still like to be under your care, please. I want to start having babies in the next few years, I need you! ~ Peace & love, Dakota”

“Yes! You betcha babycakes! U R my MD. XOXO”

“I don’t belong to a big insurane company plan—thank goodness. I get to see any doctor I want—and that’s you! ~ Blessings, Lynn”

“Hi Pam, I’m Yours. ~ Love, Roni”

“no”

“YES . . . till death do we part. I will always be your patient and you my doctor. Love, Sheri”

“Yes! THANKS for preserving your own sanity in a weird world!”

“Yes, yes, yes.  One thousand times yes . . . I am so happy you are my doctor and proud of the work you are doing to improve the way medicine is practiced. Rock on, Dan”

“No.”

Honesty is the prerequisite to all successful relationships. When patients and physicians have the courage to be honest with one another, healing begins.

Pamela Wible, M.D. is a family physician and pioneer in the ideal medical care movement.

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Doctor’s death an ‘inconvenience’ for patients →

An investigation is underway after a Chicago-area doctor is found dead—a suicide according to the medical examiner. What demands investigation is the callousness with which the this doctor’s death was reported by the media—and received by neighbors, many healthcare professionals themselves.

I’m alerted to the death initially by a Facebook friend: “Pamela, check this out!” Headline: Police: Doctor found dead near hospital in Berwyn. (Interesting side note: on 4/21 ABC news changed this headline to “Man found dead near hospital in Berwyn.”)

The facts:

On Thursday, April 16, a maintenance worker calls the police to request a well-being check on a tenant, Dr. Jon Azkue, a 54-year-old physician employed at MacNeal Hospital.

Police discover his decomposed body with suicide note surrounded by helium tanks. Mistaken as propane tanks, police call the bomb squad and evacuate the 4-story building which primarily houses healthcare professionals and medical businesses. How do his neighbors and colleagues respond?

“I was actually going to get some baby food,” says Jemin George. “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.

Anna Futya, clinic manager at the retinal clinic, 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 Dr. Jon Azkue. The headline clearly states: “Doctor found dead near hospital in Berwyn.” So why is the focus on inconvenience to patients? How did the dead doctor get scrubbed from the story?

Who is Dr. Jon Azkue? 

My online research reveals that Jon Azkue is a foreign medical graduate from Central University of Venezuela who was a senior internal medicine resident at MacNeal Hospital at the time of his death. He was just a few months away from graduating.

In this news report, Dr. Azkue is treated as if he is guilty of a crime. There is no expression of sadness for the loss of this doctor—presumably a man who spent his entire career caring for patients in at least two countries. In the comment section—amid jokes about terrorist plots and remarks about the selfishness of suicide—Doc T 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.

Facebook comments continue throughout the afternoon where Cailean Dakota MacColl, a premedical student, is equally appalled. “Hi Patient X, your doctor is selfish and died by suicide so they cannot do your eye exam today.”

Heather Springfield, another premedical student, chimes in:

I had the same line of thoughts. What a sad situation that a fellow human being who dedicated their life serving/helping others, is considered an inconvenience. It’s pretty damn ridiculous that society cries for its physicians to have an open doctor-patient relationship—to not be robots—but the moment a doctor shows their shared humanity, either they’re sued/abused/or die by suicide because they can’t take it anymore… etc. etc. What the hell is wrong with people? I wish, as a populous, we’d stop acting as if we live on separate planets when in fact, we share one planet. How hard is it to take a moment, and realize we lost a precious life to something preventable? It’s a damn shame, and my heart mourns such a loss…. This shouldn’t have happened. Shame on those residents, clinicians, and those who don’t take pause for what this is.

Physician suicide: more questions than answers

With his suicide confirmed, the real investigation must begin. Why did he die by suicide?

And why do we lose more than 400 U.S. physicians each year to suicide? Why are these suicides not investigated?

Like most suicided doctors, Dr. Jon Azkue left a note. Why are we not analyzing these suicide notes for common themes to prevent future physician deaths?

Sadly, we are unlikely to hear any more about Dr. Jon Azkue. We will not hear about the many patients he cared for, the lives that he saved. This is his 5 minutes of fame.

Pamela Pappas, MD, a psychiatrist writes:

Rest in Peace, Dr. Azkue. Being a resident at age 54 is not easy, and I’m wondering about his life and what led to this kind of end. No mention of family being notified before releasing this news to public, etc. Our culture (both medical and non-medical) apparently regards doctors as dispensable. Yes, of course patients are ‘inconvenienced’ when a doctor dies! Houston, we have a PROBLEM here, and we need serious remediation.

Why is this news story so unsympathetic to this deceased doctor?

And why are clinics, hospitals, and medical schools so willing to sweep these deaths away—often with no debriefing for survivors. Why are physicians not receiving routine on-the-job mental health support for such a high-risk profession?

Georgia Jones, a Facebook friend, shares:

This is so sad. They [doctors] deserve to have therapy without being judged or the worry of losing their job. Schools need to start preparing students for what is to come, and have help in place if they become emotionally overwhelmed. It’s so sad that this is still happening. Doctors are human beings, like us. Start treating them as such. They’re not machines! They have emotions, and believe it or not, the death of their patients DOES affect them!! Give them a break! R.I.P. Dr. Azkue. I’m sorry it came to this.

Here’s the truth: until we investigate why this doctor died by suicide, we will continue to lose more doctors. Maybe if we took a sincere interest in Dr. Azkue’s death, we could prevent the next one.

Incidentally, Kim Aaronson, a chiropractor in Chicago, adds:

Here’s another note of interest, a local chef here in Chicago died by suicide on Tuesday of this week. It has remained in the news every day. (even covered in this NYT article) The doctor’s suicide has not even been mentioned. There is clearly uneven coverage going on here…. The FB comments show the kind of empathy the press should have shown…. You are so right on, a doctor dies and it seems that no one cares at all….

Pamela Wible, M.D., reports on human rights violations in medicine. She is the author of Physician Suicide Letters—Answered. Struggling? Need help? Contact Dr. Wible.

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It’s March 30th. Have you hugged your doctor? →

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I’m in a room full of doctors at a my mom’s 50th medical school reunion when I announce, “It’s almost March 30th!” I Pause. “Doesn’t anyone know what March 30th is?” Nobody has a clue.

March 30th is National Doctors’ Day! Who knew? I never heard of it—until a friend told me last week.

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Veterans know about Veterans Day. Mothers know about Mother’s Day. Lovers know about Valentine’s Day. Why don’t doctors know about Doctors’ Day? Maybe because nobody celebrates it.

But a quick search leads me to a site that proclaims “National Doctors’ Day Gift Ideas for 2015 Are Here!” According to this official gift-giving site of The National Doctors’ Day Organization:

National Doctors’ Day is held every year on March 30th in the United States. It is a day to celebrate the contribution of physicians who serve our country by caring for its citizens. The first Doctors’ Day observance was March 30, 1933 in Winder, Georgia. Eudora Brown Almond, wife of Dr. Charles B. Almond, decided to set aside a day to honor physicians. This first observance included mailing of greeting cards and placing of flowers on graves of deceased doctors. On March 30, 1958, a resolution commemorating Doctors’ Day was adopted by the United States House of Representatives. In 1990, legislation was introduced in the House and Senate to establish a National Doctors’ Day. Following overwhelming approval by the United States Senate and the House of Representatives, on October 30, 1990, President George Bush signed S.J. RES. #366 (which became Public Law 101-473) designating March 30th as National Doctors’ Day.

Each year we lose over 400 doctors to suicide—the equivalent of an entire medical school. Doctors struggle. Doctors suffer. Doctors grieve. But doctors usually keep their feelings inside.

My recent essay on the viral photo of the ER doctor grieving the loss of his patient opened a physician floodgate of feelings. Many physicians came forward to share their stories of grief. Diane Lyn writes:

The truth is—You don’t have TIME to grieve. Because there are people inside waiting to be seen. I clearly remember in residency having to sit with my attending and tell 3 adult children that both of their healthy parents were dead. Car accident. Fifteen minutes later I was making faces at a 2-year-old so I could look in his infected ears [and I was] thinking these parents have NO idea what I’ve just been through.

Patients have no idea what doctors have been through because doctors don’t usually tell anyone what they’ve been through. When we tell our stories, we allow others to empathize with us. Amy, a psychiatrist, shares her sorrow—and a solution:

I am a physician and my husband is an ER doctor. He rarely talks about work. It is too hard for him emotionally, particularly when children die as we have two young sons of our own. The last time I went to visit him at the ER, a young child had passed away from drowning. I can’t imagine how the doctor working with that family was able to move on with her day and see other patients after such a tragedy. She was crying in the hallway when I walked into the emergency department. All I knew to do was give her a big hug. I am a psychiatrist and it is not rare for me to be brought to tears by stories I hear from my patients. It is an emotionally taxing job, one that does not allow for having a bad day of my own. I take my phone with me everywhere, answering calls, text messages, and emails on vacations and weekends. It eats away at the time I have with my own children but I do it because I care and because of the pure joy that I feel when someone returns with a good report or does something positive they never imagined that they would accomplish. I have an envelope in my office that contains thank-you notes and letters from previous clients. I encourage anyone who has had a good experience with their doctor to be proactive in sharing their gratitude. I can’t even begin to express how meaningful those moments of joy and positivity are in a career that can be so intensely heartbreaking.

How do patients react when physicians reveal their feelings? The oupouring of public support for the ER doctor crying in the viral photo speaks volumes. On my Facebook page, Carla Sallee responds, “This really touched me. I want to hug every healthcare worker I know right now. I don’t know that I ever, ever empathized with my healthcare professionals as much as I now feel I should.”

On March 30—our national day of thanksgiving for doctors—you can officially celebrate your doctor. But how? Drop off a box of chocolates? Bring a bouquet of flowers? It’s really the simple things that matter most. Here’s what my friend Butch does for his docs:

I have sent quite a few thank-you cards to doctors over the years. I quit because I thought they may be taken wrong or just too much and adding to their junk mail. Thank you for letting me know it is OK to do, Will be sending more now that I know they do help. Helping them to feel appreciated was the whole purpose anyway. Thank you for everything you do.

A few words of appreciation can help your doctor survive amid sometimes unbearable suffering. More than once, my colleagues have shared that a kind gesture by a patient made life worth living again. So give your doctor a card, a flower, a hug. The life you save may save you.

Thank you!

~ Pamela

P. S. While you’re at it, thank your nurse, dentist, and veterinarian too! Looks like they have national holidays that nobody seems to celebrate either.

Pamela Wible, M.D., is a family physician and pioneer in the ideal medical care movement. She is active in medical student and physician suicide prevention and leads biannual retreats to help her colleagues heal from grief and trauma.

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Heart-Wrenching Photo of Doctor Crying Goes Viral. Here’s Why. →

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Outside of a Southern California hospital, an ER doctor is crouched down against a concrete wall grieving the loss of his 19-year-old patient. A paramedic snaps a photo of the tender scene. His coworker, a close friend of the doctor, posts the photo (with permission) online. Minutes after the photograph, the doctor returns to work “holding his head high.” Thousands of people have commented on the web. In their own words, here is why the photo went viral:

1) Humans crave raw empathy. The photographer captures a poignant moment in a stoic profession that trains doctors to remain professionally distant. The voyeuristic photo reveals the emotional reality of doctoring—and a side of physicians that people don’t usually see—while uniting us all in our common humanity.

2) Unexpected death is universally heartbreaking. An ER doc, Smeee, writes:

When it comes to our work, nothing is harder—and I mean nothing—than telling a loved one that their family member is dead. Give me a bloody airway to intubate. Give me the heroin addict who needed IV access yesterday, but no one can get an IV. Give me the child with anaphylaxis. But don’t give me the unexpected death. . . . We can only do so much, and we can only hope to do our best. But it’s that moment, when you stop resuscitation, and you look around, you look down at your shoes to make sure there’s no blood on them before talking with family, you put your coat back on and you take a deep breath, because you know that you have to tell a family that literally the worst thing imaginable has happened. And it’s in that moment that I feel. And I feel like the guy in this picture.

3) Doctors are not allowed to grieve. A surgeon, TheGreatGator, shares, “We are never formally trained to deal with loss and/or with giving the worst news of a families life to them.” Another doctor, boldwhite, writes:

I know what that person is feeling. Yesterday one of my 17-month-old patients died. I was in the bathroom crying in private between patients several times yesterday. I’ve cried in stairwells and hallways. It eats at you. Life is very fragile and the pain of losing those we are trying to help becomes a scar that doesn’t go away. It has shaped who I am as a person.

4) In medicine, crying is unprofessional. That needs to change—now. A premedical student volunteering in the local ER tells me about a female physician who cried after losing a child. He thought her behavior was unprofessional. I asked him to consider, “Who did she harm by crying?” Meanwhile, a physician tells me she’s been cited for unprofessional conduct for crying at work. Her boss told her, “Unless you are dying, crying is unprofessional behavior and not to be tolerated.” Some physicians and young doctors-in-training are uncomfortable with tears. Grieving is a healthy reaction to sadness. Humans bond through shared pain. Please do not punish your colleagues for their willingness to be vulnerable with grief-stricken families. Real doctors cry.

5) Patients want doctors who cry. Patients are comforted when doctors grieve with them. Vicki Allemand Scott, a mother on Facebook, concurs, “When my daughter passed away the doctors and nurses formed a wall in front of us until she was gone. ALL of these wonderful people were crying just as much as we were. I will never forget the kindness and compassion we were shown by these special people.”

6) Real men cry. Men are socialized not to cry. This photo honors a man for having the courage to cry. A son, livinbandit, shares:

My dad is an ER doctor, and has been for as long as I’ve been alive, always working nights. He doesn’t usually talk about patients, but he would talk about the gross things he’s had to deal with around the dinner table with the family. The times that I do remember though, however rare they were, were the times he would come home, and cry in my mother’s arms because there was someone that he couldn’t save no matter how hard he tried . . . He didn’t think any of us kids were watching, but I seemed to always see. I’ve never had more respect for my dad then when I would see him cry because he felt like he could have done more . . . Even if he couldn’t have.

7) More than anything—doctors need your empathy. What happens when the physician in the photo pulls himself together and gets back to work? One commenter on Reddit, PM_YOUR_PANTY_DRAWER, suggests the sad reality:

The part most people fail to realize, is that this man now has to compose himself, walk into another person’s room, and introduce himself with a smile and handshake to the next person. Sometimes healthcare workers walk in to see someone new and before even introducing themselves, out comes; ‘We’ve been sitting here for 45 minutes and . . .’ or ‘That guy next door has been moaning forever and nobody is helping him.’ You literally had to direct yourself 100% at someone grappling with death, and the rest of the show goes on around you. There’s times where you run, and rush, and hurry, and skip eating, and go 12 hours without urinating, and you’d give your firstborn for a cup of water, and through it all, you lose, you get complained to, and you get zero sympathy from your coworkers or management. I’ve been covered in phlegm, urine, feces, blood, infectious drainage, sweat, and tears. I’ve had to go from ensuring a person continues to breathe, to a room full of angry people because grandma wanted a Tylenol and the call light has been on for 10 minutes, and we’re going to another hospital, and we want another doctor, and this place is getting a call to the administration, and I’m going to call a lawyer, and I’m calling channel 6 news, and we know so-and-so and he’s going to hear about this. Healthcare is a life of fighting, defending yourself, sacrificing yourself, working weekends, missing holidays, and sometimes things like losing a patient makes you want to throw up your hands and say ‘fuck it, I’m out.’ But you can’t. You do it because you love it. You do this thankless and unappreciated job because you want to. I can’t believe I’m in 6-figure debt and gave up the nights and weekends of my 20s so I could voluntarily do it. But I couldn’t see myself doing anything else.

One doctor, jimbomac, has a simple request: “Let me tell you those ‘thank-you’ cards probably mean more to us than you think . . . we do hugely appreciate when people like yourselves take the time to say thanks.”

8) Doctors who don’t grieve get sick.  Unprocessed grief is dangerous for human health. My Facebook friend, Joe Jacobs, writes:

I had a friend who was consuming heavy amounts of cocaine in the 80s trying to deal with a doctor’s life. He was a Cedars doctor making big bucks and living a prestigious life so I asked him why and he responded with. Paraphrase: I’m an oncologist who thought I would be able to help using the latest cure methods. I find myself head of the ward of incurables and it is my job to ease their pain and watch them die and then watch the response of family members to the outcomes.

9) If you don’t cry, you die. In my recent article, Physician Bullying: ‘Not Allowed to Cry’ I discuss unprocessed grief as a root cause of physician bullying, abuse, depression—even suicide. Both men I dated in med school died by suicide. Brilliant physicians. One overdosed at a medical conference. The other overdosed after work. In just over a year, we lost three physicians in my town to suicide. Gunshot wounds, mostly. One local doc lost seven colleagues to suicide—so far. Our profession punishes doctors for grieving and restricts the medical licenses of those seeking mental health care. So rather than process our grief, many docs turn to alcohol, drugs, firearms.

10) The physician in this photo is a modern-day hero.

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Attention: Male physicians—join our upcoming retreat!

Pamela Wible, M.D., leads physician retreats to help her colleagues heal from grief and reclaim their lives and careers. Watch her TEDMED talk “Why doctors kill themselves” and her TEDx “How to get naked with your doctor.”

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My testimony in support of medical student mental health to the Missouri State Legislature for House Bill 867 →

I’m Dr. Pamela Wible, a family physician in Oregon. I’ve submitted my CV, witness form, and transcript of my testimony to Chairman Frederick. My schedule prevents me from traveling to Missouri for today’s hearing; however, I thank Vice Chairman Morris and the Committee for allowing me to testify remotely in support of House Bill 867, legislation that would require Missouri medical schools to screen students for depression and offer mental health referrals for those at risk.

Medical Student Stress *

Medical students face enormous stress. Their workload and debt load are immense. They witness incredible human suffering with no emotional support or debriefing. Routinely sleep deprived, they’re groomed in a medical culture that rewards self-neglect and often condones bullying.

Medical students are afraid to seek help for fear of retaliation or discrimination. Medical students are afraid to seek counseling because medical boards like the one in Missouri ask applicants if they’ve ever been treated for mental health issues. Checking the “yes” box can lead to a subpoena of one’s “confidential” medical records.

Medical students enter medical school with their mental health on par with or better than their peers. Up to 30% develop depression and 10% become suicidal during each year of medical school. Both men I dated in medical school died by suicide. Depression and suicide are known occupational hazards in medicine.

More than 400 U.S. doctors die by suicide annually. Widespread underreporting and miscoding of death certificates suggest the number is closer to 800. That’s like losing all 391 medical students enrolled at the University of Missouri Columbia School of Medicine plus the 433 students at the University of Missouri Kansas City School of Medicine— every year.

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Please join me in support of House Bill 867

House Bill 867 benefits medical students. This bill will de-stigmatize mental illness and normalize medical students’ rights to request and receive confidential mental health care. Student participation is voluntary and student data remains anonymous unless students select otherwise.

HB 867 benefits families by making mental health data transparent across all 6 Missouri medical schools. In medicine, informed consent is the standard of care, yet medical students and their families have not been informed of the health risks of a medical education.

Last fall, I attended a funeral. Kaitlyn Elkins was a star third-year medical student described by her family as “one of the happiest people on this Earth.” She died by suicide, but the funeral wasn’t for Kaitlyn. It was for Rhonda Elkins, Kaitlyn’s mother. Unable to recuperate from her daughter’s suicide, Rhonda took her own life. I asked Rhonda’s husband, “If Kaitlyn worked at Walmart, would she and your wife still be alive?” He said, “Yes. Medical school has cost me half my family.”

HB 867 also benefits patients. The best way to care for patients is to first care for our doctors-in- training. Let’s practice what we teach. By truly caring for our medical students we demonstrate how we expect them to care for patients. The cost of not caring for our young doctors-in-training is more tragedy. Each year nearly 1 million Americans lose their doctors to suicide.

Finally, I support House Bill 867 because it benefits medical schools. We teach medical students the value of evidence-based medicine, but if our medical schools are exempt from collecting evidence on medical student depression, how can we evaluate student mental health? How will we know the impact of medical school wellness programs? The psychological well being of Missouri medical students is just as important as their academic performance. This bill finally gives us the data we need to properly care for and educate the future physicians of America.

On behalf of all medical students nationwide, I thank you for your support.

 Click here to read House Bill 867

UPDATE: On May 12, 2017, after 3 legislative sessions, the bill has now PASSED into law. Thanks to Keith Frederick for his tireless efforts!

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Pamela Wible, M.D., is a pioneer in the ideal medical care movement. When not treating patients, she dedicates her time to medical student and physician suicide prevention. Dr. Wible is the recipient of the 2015 Women Leader in Medicine Award.

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