The Dark Side of Doctoring

The Dark Side of Doctoring

Posted on 13/05/2017 by DrEricLevi

Episode 1. I’m a surgeon. I’d like to think that I’m resilient and well adjusted, having gone through medical school and rigorous surgical training. I’ve been a doctor for 13 years and much of that period has been spent training to be as good a surgeon as I could ever be. I have great family support, a physician wife who understands my work and I’ve never been diagnosed with a mental illness.
The suicide death of Dr Andrew Bryant, a Brisbane gastroenterologist last week hit a raw nerve. His wife wrote this honest and courageous letter.

Although I’ve never had serious suicidal thoughts, I – like many other doctors – have been through many dark seasons. Depression, anxiety, burnout, suicidality, hopelessness, lethargy, anhedonia, feeling flat, worry, and the like are all different flavours of the same phenomena: the negative human response to internal or external stressors. Of course, the causes are always multifactorial. It cannot and should not be oversimplified to family history, genetics, behavioural deficiencies, bad environment or poor social support.
When I carefully dissect my dark seasons, some common themes often emerge. Work is often the critical exacerbating and perpetuating factor in those dark times. Because as a surgeon I spend the vast majority of my lifetime at work, what happens there influences all other aspects of my life including my marriage, family and social life.
Here are 3 common things that have thrown me into some dark pit of despair:
1. Loss of Control
I have lost control of my days. I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off. When I was preparing for surgical exams, I’d be working and studying from 6.30am to 10pm everyday, seeing my family only on the weekends for lunch. I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car. I used to have my sleeping bag, toiletries and change in the boot of my car because I didn’t know if I was going to make it home some nights. Plans change every single day at work because of emergencies. I can’t even be sure what the next hour will bring when I am on call. You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call. The intensity and personal damage of these on call periods are often forgotten.
Not only that, we are losing control of health care in general. Everyday, there’s a new form, a new guideline, a new protocol, a new health software, a new policy all dictating, restricting and modifying clinician activities. Some of these policies are written by people who do not see patients. There’s a whole paid industry dedicated to restructuring what doctors and nurses do to reduce costs and increase output.
2. Loss of Support.
Just imagine. I start my days at 6am. I wake up to an email alerting me of the number of discharge summaries that haven’t been completed and the various computer based modules I have to complete (hand washing, privacy, lifting patients, etc). Round starts at 7am. I see 15-20 patients with various travel forms, certificates, scripts that need completing. All to be done via the electronic health system, clunky, not user friendly, takes a long time to log in. Then I start an overbooked operating list at 8am. There are 7 cases booked. I have no say on who gets on the operating list and the order of patients. The first patient haven’t been checked in. The diabetic one is hypoglycaemic. The infant is cranky. The autistic child is running away. The interpreter is not here yet. The computer is still not logging in. The password is expired. I used to be able to arrange the operating list because I know that some operations take longer than others. But now, the bookings office determine that that all my tonsillectomies take 14 minutes because that’s the average time recorded on the computer. The moment I scrub in, the timer starts. The moment I unscrub timer stops. Click. Click. Click. Because the theatre bookings does not take into account the interpreter time, pre-med period or transfer to ICU, the list is running late. The nurse in charge is breathing down my neck to finish on time. I still took about 14 minutes on each case, but the team is delayed by external clinical reasons. The theatre team is anxious to finish, everything is rushed, and mistakes are bound to occur.
In the mean time, I field 12 phone calls from ED, GP and other units. By now there are 3 patients waiting for me in ED and 1 being flown in from another hospital. The operating list is finished late. I rushed to ED, and gulped down a cup of instant coffee. Then I arrive late to the afternoon clinic, which again is overbooked. Clinic nurses are not happy. I see 8-10 patients while taking more calls. I try to discuss complex surgeries with patients but I keep getting interrupted by calls and paperwork. Then I run back to theatre for an emergency case. By this time I’m set up for failure. I’m tired, cranky and my head is full of jobs to do. I do the afternoon round, see more consults, admit more patients and dictate letters. I have taken up to 70 calls on a 24h on call period. By 6pm I’m totally exhausted. I grab a packet of chips, ginger beer, and start working on the papers I was meant to write up. I review the case notes for the next couple of days. I get home between 7-8pm. Grab dinner and put the kids to bed. I get called back in and I take a patient to theatre for an emergency procedure. I come back just after midnight and sleep. I get called four more times between midnight and 6am.
6am. Repeat.
I have lost control of my days and I have lost support. When can I actually find support? I don’t have time to talk to my colleagues about life. I don’t have time with my family. I don’t have time to catch up with friends. Social ties are lost when one stepped into medical school. I’ve lost count of the number of significant life events I have missed (birthdays, anniversaries, reunions, school recitals, first walks, etc.)
I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital.
I know where I can get support, but practically, when and how am I going to get that support?
In addition, doctors who scream for help may be formally reported, therefore having restrictions placed on their practice and then incurring higher medical indemnity fees in some situations. Trainees who ask for help may be labelled as underperforming and have to be commenced on probation or remediation. We may not have practical access to the support that are often advertised.
3. Loss of Meaning
Interestingly, the above physical and emotional stressors are reasonably manageable to me. I’m understanding my own physical and emotional limits. These stressors induce exhaustion, but the excitement of the work and the intellectual challenge of the job bring a lot of personal satisfaction. I do get emotionally shaken at times because I deal with dying cancer patients, emergency airway disasters and sick complex children, but I get by.
I am realising more and more that what brings me greatest distress is the relentless administrative pressure which take away the meaningful clinical engagement I have with my patients. And I wonder if this is what many young doctors are experiencing as well. Medicine used to be a meaningful pursuit. Now it has become a tiresome industry. The joy, purpose and meaning of medicine has been codified, sterilised, protocolised, industrialised and regimented. Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators.
I have little say in organising my very own operating lists or clinics. Even the power to re-order the operating list has been taken from the surgeon. The thing that I love doing (operating & seeing patients) is being measured, recorded and benchmarked. The clinics are overbooked to get numbers through. The paperwork for each patient encounter is increasing with each passing year. There are so many other non-clinical departments dictating what I should do and how best to do it. The mantra is “cost-effectiveness and increased productivity.”
I went into medicine knowing that I will have to sacrifice much for the sake of my patients. What I am realising is that today in modern medicine, a doctor is just one of the many commodities in this complex industry. It’s no longer about the patient. It’s about the business of hospitals. Patient satisfaction officers, Theatre Utilisation officers, Patient Flow Coordinators. These are all business roles.
As a surgeon I spent a year in a hospital where I smiled on the way to work and I am so grateful for my job. I looked forward to long days because I knew what I was doing was significant. Another year in another hospital, I dreaded going to work. I hated being on call. I was burned out and I couldn’t control my emotions at work and at home. I’m not inherently an offensive or rude person, I’m just a person pushed to the limits and set to fail because of the circumstances around my work. Same surgeon, different jobs. The forces that pushed me to losing control of my emotions are likely the same forces that might push some of us to suicide.
To some hospitals and their business, I’m not a Surgeon. I’m just an employee. Overworked, burned out, replaceable. The noble call to Medicine has been suffocated by the bureaucratic force exerting itself as the medical industry.
This is Episode 1 of a Trilogy.
Episode 2: The Dark Side Awakens
Episode 3: Restoring Hope and Humanity to Health Care. Here I write about the 3 corresponding antidotes to the 3 issues above. 
Would you agree or disagree with my thoughts? What other “Dark Side of Doctoring” issues can you think of?
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 LJ 20/05/2017 at 7:20 AM

Thanks Eric. You have voiced the pain of being a happy doctor which lot of us are! I am paediatric allergist in rural Victoria.
Over decade/s+ of basic and specialist medical training, most of us ignore the very principles of good physical and mental health for ownself irrespective of our learnings about better health. It was nt until I took a career break to care for my young child when I started to realise how me and my paediatrician husband had kept healthy habits away during our ‘career’ build up. Not only we did nt care for ourselves, we never stopped to think how our daily routines were not good for environmental health where our future generations will live their lives.
I have now been working part time for 3 years to get more out of work life balance . At times it becomes very tempting to earn more money by working more hours, something which is in such easy access. Instead I choose to use my unpaid hours to deal with overwhelming admin responsibilities in a salaried job rather than using that time to earn more money. As you said, poorly supported admin workload takes some pleasure out of my work gratification too. Better IT system is the way forward to improve quality and quantity of care without weighing down upon doctor’ s family time.

I think its time we all look after ourselves to keep providing good care to our patients for longer.
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 Alex J Crandon 20/05/2017 at 5:43 PM

LJ, You have done the right thing. A couple of months ago I moved into semi-retirement and it was the best thing I’ve done for a long time and one that should have been done years ago. We do need a better work/life balance.

The only thing I would otherwise comment on is your statement that ” Instead I choose to use my unpaid hours to deal with overwhelming admin responsibilities in a salaried job ……….” As long as you use unpaid time to do what should be paid work, the more the bureaucrats/administrators believe we can do the administration in the allotted time, of which of course there is generally none.

Some time ago I stopped working for nothing. When Admin asked why things (paperwork) weren’t being done I asked them to identify for me the time allocated for this administrative work. Of course they couldn’t and so they decided that they had better allow some paid time for the paperwork or none would be completed.

The longer we do this for nothing, the longer will Administration expect us to continue; please for the sake of our colleagues don’t do it.
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 Stephen Coppinger 20/05/2017 at 6:19 PM

Absolutely right. For years I tried to get my colleagues in the U.K. to take a stand but to no avail. Many years ago the managers used to accuse clinicians of ‘shroud waving’ when they pleaded for resources. Later, they regularly relied on our compassion and professionalism to impose more work (in the shape of targets), more paperwork and loss of autonomy, confident that most would not stand up on their hind legs and act like you have. If you look at the sad history of the demise of autonomy and professionalism in medicine you must (certainly in the U.K.) look at the supine attitude of the majority of medics. My generation are not victims: their inability to stand firm is at least partly responsible for current situation.
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 Alex J Crandon 21/05/2017 at 11:25 AM

Stephen you are absolutely right. Trying to organise doctors is literally like trying to heard cats. Why this is the case I wont go into. However, while the doctors themselves can’t work as one, I am appalled at the disinterest and apathy shown by representative groups such as the BMA and the Australian Medical Association (AMA) to say nothing of the specialist Colleges who are supposed to be primarily driven by maintenance of standards.
While a large proportion of the profession are constantly appalled at the useless, time and money wasting bureaucracy that constantly erodes our time, our professional representative groups appear to pay no attention at all. These bodies pay lip service to many of the problems. They encourage such things as work/life balance but exhibit no objections to the increasing paperwork that erodes our Quality of life.
In Australia I can remember moving interstate (New South Wales to Queensland) about 25 yrs ago. At that time all I needed a copy of my NSW registration and identification. I went to Queensland’s State Medical Registration Board and once my paperwork was confirmed, by a phone call, I was Registered in my new State to practice. I then attended the hospital where I would work and they asked to see my Qld Medical Registration which showed I was a Registered Medical Practitioner and a Registered Specialist. I was then welcomed by a small hospital administration, all of whom had a Medical background and many of whom were in active Staff Specialist practice, and told I could start work the following week. The presumption was, that if I had my General Registration from Queensland Medial Board and I also had Specialist qualifications from the Royal College of O&G and from Royal Australian College of O&G then I was a recognised Specialist in the field of O&G and could do my job in that Specialist field.
Several years ago we did away with State based Registration and replaced it with a National Registration. This was done in part to simplify the problem of working close to a State border or in more than one State where every year you had to re-register in two States and pay fees to both. The new National Registration process meant we Registered once and it applied national wide.
Not long after that every hospital (both public & private) decided to introduce hospital based Accreditation and Scope of Practice. This effectively re-invented the wheel that belonged to the National Registration organisation, only the hospital based one involved 3 – 4 times the paperwork which included everything that the National Organisation had already done. This was further aggravated by the fact that if you worked at more than one public hospital under the same Department of Health, all of these individual hospitals demanded you do their own hospital based accreditation and Scope of Practice. If you worked at a few different private hospitals, albeit run by the same private health organisation, each hospital wanted their own hospital based paperwork; it wasn’t good enough that you’d done this at hospital A. Hospital B would generally not accept a copy of the paperwork you had provided to Hospital A. Hospitals, usually private, are now asking for certified copies of initial degrees, College Diplomas and identification which is extremely time consuming.

Now the National Registry organisation is pushing on with a process of introducing some form of re-assessment, that has already as I understand, been trialled in the UK and was extremely onerous and accomplished nothing useful.
Not only is all of this paperwork extremely tiresome and time consuming, taking us away from our families and our patients but no one has as yet shown any evidence that it accomplishes anything that benefits the outcome of patients. All it seems to do is provide quasi protection for hospital administration and in the process employ innumerable bureaucrats to shuffle these papers and whose wages/salaries consume an ever increasing proportion of the health dollar which is much more needed at the coal front. When renewal is due it isn’t good enough to ask us to sign a declaration to the effect that nothing has changed. No! They send another 14 page totally blank Application form by email and tell you it has to be submitted electronically with all of the supporting evidence/information scanned in. Too bad if you don’t have a scanner because they refuse to accept it on paper.
The examples of this are almost endless; asking senior surgeons with 30+ years experience, to scrub under the watchful eye of a nurse who will assess whether or not they think they are doing it correctly; this is not only demeaning and unprofessional, it’s offensive. Demanding senior staff do tests to demonstrate their ability to undertake processes/procedures they would never do.
Meanwhile, our professional representative groups, be it the AMA or the BMA or the Specialist Colleges sit n their hands and say nothing about their members problems. They certainly don’t stand up and say: “No! Enough is enough until you can show some evidence that this improves patient outcomes”.
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 Dobbo 20/05/2017 at 11:08 PM

Eric,after reading episode one,my wife said that could have even me. Thank you for this timely article that shows how vulnerable we all are when the circumstances collude against us.
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 DrEricLevi 20/05/2017 at 11:25 PM

Thanks Dobbo! You’re the legend that has taught me well.
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 Jennifer 21/05/2017 at 7:10 AM

Hi Dr Eric and all.
Thank you for a beautifully honest article, one that has brought up much for those who have read this. As both the article and the comments what I could feel is that healthcare is sick, especially when you read about how we are with each other as health professionals in healthcare, regardless of our role. I work as a registered nurse and have a growing appreciation and respect for my medical colleagues and visa versa. I had a GP call me the other day, just to talk about a particular patient. We have never met face to face, but we have connected on the phone many times and what we had was a very supporting conversation for both of us.
Unfortunately what we see and get told about in healthcare is what we need to improve on, what we need to do better. We rarely get confirmed for what is in fact quite incredible. Lets face it we know that we all do amazing work and than none of us would be able to do what we do without everyone else in our respective teams. However even within those teams there is the poison on jealousy, comparison, competition and that fact that a lot of us are just plain exhausted and the impact that this has on all of our relationships.
We know that the usual fixes don’t work as we see them come and go and often come back again. But we really can’t approach what is going on in health with the same approach that which created what we currently have. Otherwise it’s more of the same.
However with all of this and with all that has been shared what I can mostly feel is that we actually don’t deeply deeply appreciate who we are, and what we have chosen to do in our life. We have chosen to step into the mosh pit of life and commit to people day in and day out. It’s more than the function of whatever job we perform, it’s that we have chosen this and that what we bring and offer is very needed.
Yes we all have particular skills related to our jobs, but the function of this has become more important that the quality of ourselves that we bring to our work everyday. This needs to be nourished, supported and grown everyday, much like the skills that we develop. It is of no less importance. When we nourish and support ourselves as people, this then very naturally extends to our work and we become less and less overwhelmed with all the other demands that are placed on us. It does mean that we won’t be incredibly busy. But what is does change is how we are with ourselves in that busyness.
While we all like to ‘see’ the results of our work and ‘see’ what that brings to a patient and their families, its the quality of what we offer as people that we have a lasting effect, and may only seem small on the outside, but can be quite significant for the person in their whole life. This comes from nurturing and caring us first. Then we bring that quality to all we meet and do.
In appreciation

Jennifer
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 DrEricLevi 21/05/2017 at 7:22 AM

Thank you.
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 Barbara 21/05/2017 at 11:16 AM

Hi Eric!

I am moved that finally a doctor has voiced out what we teachers have felt and gone through all these years. Any profession that involves contacts with fellow humans is bound to suffer like this when those up there who are not at the front line stick their sticky fingers into our work.
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 Christy 21/05/2017 at 12:17 PM

I think thinks a wonderful piece.

But are we doctors ready to make the changes that need to happen a reality. Are we willing to accept that we are not super humans. I think we are to blame for the predicament we find ourselves in and we need to be the change agents if we really believe there is a problem. And yes I do think there is a problem.

I am 56 years old and have been practicing since 1991. I have decided that I will not do on Call as it conflicts with everything I try to preach to patients about quality of life. I am not advocating everyone does that but we need to take a stand.
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 Mark Ready 22/05/2017 at 8:58 AM

Dear Eric

Thanks for your letter. As a radiologist my life is nothing like yours. Not as busy or stressfuI, still have a degree of disatisfaction mainly due to commoditisation of radiology. Most number of cases in shortest possible time at the chespest price.

All the compliance rules are a real pain.

The night call for spurious CT scans driven by the ridiculous 4 hour rule in Emergency departments has driven me to distraction. So much so at 64, I have withdrawn from overnight call.

Mark
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 Burned Out 23/05/2017 at 11:28 AM

Hi Eric,

I am a critical care fellow physician in the united states. I stumbled across your blog at the perfect time…as someone who is utterly tired and exhausted, burned out and unable to shut off my mind and looking at Facebook, trying desperately for a way to decompress from my work in the ICU.
I relate to you very much. I cannot remember my last day off, I have missed so many holidays I have lost count and honestly don’t want to know because it makes me depressed. I was unable to not only call my mother on mother’s day, but haven’t spoken to her in months. I struggle to cook, clean, laundry. I am required to do extra medicine things outside of my constant daily and call work load (case reports, administrative burdens, schedules, reading the current literature, etc) and struggle to balance it all. I can never go home and just be home, theres always more work to do. In fact, most days I struggle to eat, pee, shower, and keep up with laundry. I ask my patients to be healthy when I myself am not. My friends are only my work friends because there’s no time to see anyone else that I used to be friends with from high school, college etc. I live apart from my husband because my training for fellowship required me to go to another state. I know that my job negatively affects my marriage at times. I stay long hours beyond what I’m technically scheduled, because the patients need me and there’s no one else to cover. In the ICU, I deal with death routinely and last week had a patient’s family scream at me for not pushing enough medications to stop their loved one from breathing all together. I am often the whipping post for families grieving and looking to take their anger out on something and someone. I have been hit by a patient before. The security never comes as fast as you need them and no one prepares you in medical school for the emotions that go through you after you’ve been hit and/or kicked by your delirious patient. I was the first one to ask a metastatic cancer patient (a true failure in our medical system that no one else before me had asked), in her 30s and similar in age to myself, whether or not she wanted to fight anymore, and then held her hand when she died later that day. After she died, I had to keep going without a breath of fresh air or any acknowledgement of my own inner feelings about her death because there was more work to be done and more people needed me. I watch patient’s I know will never leave the hospital slowly die and suffer for months. I don’t remember the last time I slept for consecutive hours in a row without my pager going off, or waking up because my pager did not go off and thinking I must have missed one. I watch my colleagues make mistakes. I myself make mistakes and no matter how small or inconsequential, they eat at me. I take my home with me emotionally and can be emotionally wrecked for days or even weeks, it affects all aspects of my life. I get burned out, yet it is considered a sign of weakness to admit that, and the “resources” that exist are a badge of dishonor if you use them. People talk about you and judge you if you ask for help with your work load or that you need a day off because your sleep deprived. Sometimes I worry about my safety with driving home after a long call shift. I had an off service fellow tell me that I am not the same person I was when he met me a year ago and that I no longer smile and laugh like I used too. He is right. From day one of medical school, through residency and now fellowship, I have been molded into a different person, for better or worse.
You put into words everything I’ve been feeling but trying so hard to suppress, trying to pretend that everything is fine and that I can be a superhero and do it all, all the time when really I get burned out. You made my feelings normal, and I am very grateful for that. Yes, I know my job is worth it, and I would choose it again in a heart beat. I also know this current state will pass like it always does, and it will again come back around again. Thank you for normalizing this for me, and for allowing me a place to post my own similar story.
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 DrEricLevi 23/05/2017 at 11:32 AM

I know exactly how you feel. We’re in this together.
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 DrEricLevi 23/05/2017 at 11:48 AM

Thank you for sharing. It helps us all to realise the stress we’re under.
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 De Waal Smith 24/05/2017 at 3:17 PM

All comments are “spot on””

I’m an ObGyn. Love my job

Feel the same : “moulded into a different personality ”

Now that we really can contribute to our patients wellbeing/health , we feel like retiring because of all above.

My 3 children are all in Med school. Why?

I think they still think they can spend 90% of their time helping people.No easy solution for our profession.

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