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--:-- Sean Rameswaram: Support for this show comes from strawberry.me. Be honest. Are you happy with your job? Or are you stuck in one you've outgrown? Or never wanted in the first place? Sure, you can probably list the reasons for staying. But are they actually just excuses for not leaving? Let a career coach from strawberry.me help you get unstuck. Discover the benefits of having a dedicated career coach in your corner. Go to strawberry.me slash unstuck to claim a special offer.
--:-- Sean Rameswaram: It's Today Explained. I'm Sean Rameswaram for him. Over the weekend, the ninth installment in the Fast and Furious franchise made something like $70 million in North America. That means a whole lot of people went back to the movies this weekend. People are well ready to get back to business as usual. And we couldn't have gotten to this point without our health care workers. They got us through a nightmare year. Unlike a lot of us who just had to stay at home or mask up when we went out or went to work, they got to see what 600,000 deaths really looked like. And this isn't over for them yet. People are still dying.
--:-- Sean Rameswaram: So it's worth asking after everything they've been through, how are they doing? Vox's Julia Belluz recently asked, and what she found is that a lot of them have been struggling with their mental health. As a warning, the show today will feature discussion of suicide.
--:-- Sean Rameswaram: I want to tell you the story of one doctor out in Utah. His name is Scott Jolly. He was 55 years old. He'd been an emergency physician his whole career, so almost 30 years. He was 5'10", he had brown hair, and he was athletic. He loved skiing, he loved golfing, but he especially loved fly fishing. He fly fished all over in Yellowstone, Island Park, Idaho.
--:-- Sean Rameswaram: Jackie Jolly, Scott's wife. His goals were to catch a fish everywhere he went. One thing that Scott's friends told me was that he was a very detail-oriented person, even in his hobbies. So with fly fishing, he would be obsessed with finding the perfect bait. He would outsmart the guys who were working in the local fishing shops about where the best place is in the rivers where he was fishing.
--:-- Sean Rameswaram: And he and his wife owned a cabin and a boat on a lake where he used to fish. He spent many, many hours on this lake putting his boat precisely where he knew a hole was. And a hole meant a lot of fish. And so he would point the tip of his boat, the back of his boat, based upon the surroundings to make sure that he was in that hole and he would be able to catch that 25-pound fish.
--:-- Sean Rameswaram: And he would make me drive the boat and make sure I was always keeping it in that angle So he would get into that hole precisely, and I would spend hours, hours out there with him. This part of his personality definitely carried over into the hospital. He was very meticulous about caring for patients. He never wanted to make a mistake.
--:-- Sean Rameswaram: And what Jackie told me, his colleagues had told her that in his career in medicine, he never had a patient complaint against him. He was just absolutely obsessed with putting his patients first. Where in his career was Scott before the pandemic began? So he was heading toward retirement.
--:-- Sean Rameswaram: The one thing that I've come to appreciate about emergency medicine reporting this story is that doctors often refer to it as the kind of dumping ground of American medicine. Basically, you have to imagine you have patients coming in in handcuffs with the police, patients who are delusional, like every type of emergency you can imagine.
--:-- Sean Rameswaram: And basically, a couple years before the pandemic, Scott's in his early 50s, and this really started to wear on him, and it started to take a toll. The things that you can do in your 30s, like, you know, doing a night shift and then sort of turning your body clock around and doing a day shift, get a lot harder the older you get.
--:-- Sean Rameswaram: That's Miles Greenberg. He's a close friend of Scott's all the way back to residency. Even a lot of practicing emergency medicine docs who are still in their 50s have really dialed back the number of clinical hours they do. And that's in fact what Scott was looking to do.
--:-- Sean Rameswaram: Everything was going really well. He had the right shift, so he was really at a good place of his career and felt like he was going to end it on a very positive note. So what happens to them when the pandemic hits? Well, at the start of the pandemic last year, you have to remember all these hospitals were expecting this massive influx of patients, and they didn't come at first in many places.
--:-- Sean Rameswaram: The caseload wasn't that high initially, but everybody was frightened, right? And everybody, you know, kind of went into lockdown. And going to the ER or other places like that for routine medical care just became things that people didn't want to do if they didn't have to. So the volumes dropped off a cliff.
--:-- Sean Rameswaram: And of course, we know hospitals are businesses. And when volumes were down, they started to cut back. And one of the cutbacks they made in Scott's hospital was on staffing. So he got reassigned from some more manageable day shifts he had been on to these evening shifts.
--:-- Sean Rameswaram: And usually in the past, they would be covered by two doctors. But because of the cutbacks, he was often working alone. And so when the pandemic started happening, he would be the only one on working with nurses or techs. And so I think that stress level as being an aging physician started taking a toll on him.
--:-- Sean Rameswaram: He couldn't spend the time with his patients that he normally did. He had to worry about wearing his PPE. He had to worry about being safe. He had to make sure his staff was safe. Scott was a perfectionist, like many physicians are, and he was already in a place where he felt like he couldn't deliver the care that he wanted to deliver the way he wanted to deliver it, and the pandemic made it like 10 times worse.
--:-- Sean Rameswaram: So by August he had kind of reached this breaking point and Jackie described one evening where he had a particularly bad experience with a patient he had stabilized a patient for some reason I seem to think it was an overdose patient drug overdose patient who I guess he thought he had gotten stabilized and then he left the room and took off his PPE to go see other patients.
--:-- Sean Rameswaram: Or changing into the next set or whatever he was doing. And she went into cardiac arrest. So he was thrushed all by himself to hurry up and get back his PPE. Kind of rushed back in there. And stabilized the situation, which he did. But it was very stressful, and when he came out, he was shaken by that.
--:-- Sean Rameswaram: That patient was the final blow of all of the other incidences that have happened to him that he lost it then. I think that's where he finally said, I can't take this anymore. This is just not good for me. You know, he was a guy who was always trying to project an air of, you know, being confident and being in control to break that facade.
--:-- Sean Rameswaram: You know, it was something that embarrassed him a lot. So Jackie wakes up the next morning at like 6 a.m. and she found Scott at their kitchen table just sitting there hunched over and basically he hadn't slept since he came home a few hours earlier.
--:-- Sean Rameswaram: I had never seen Scott like that ever from a shift. It was almost like he aged overnight He told me that the way that things had changed in the emergency room that he was worried that he was going to hurt someone and that it would ruin his career.
--:-- Sean Rameswaram: He was just terrified of making a mistake or, yeah, putting his PPE on incorrectly, you know, bringing COVID home to his family. So he had been reaching out to his supervisors to ask for another doctor to support his shifts or to move to this pre-retirement track he was hoping to get on.
--:-- Sean Rameswaram: Was Scott able to get any help? So I saw five emails where he put these requests in writing, and Jackie and Miles say that there were additional emails and phone calls and conversations with his supervisors. But ultimately, they said that because he wasn't yet 60, they couldn't move him to this pre-retirement schedule.
--:-- Sean Rameswaram: And they also didn't do anything to accommodate his other asks. I'm so angry at all of this when I relive it. It makes me so angry that he's worked with this group for 22 years and they didn't see it, that they couldn't recognize that a good partner was reaching out, saying this is way too much for me.
--:-- Sean Rameswaram: So he ended up just asking for an unpaid sabbatical, basically like a couple months off to recover, to get his mental health in order and figure out his options. And at first it sounds like it was kind of going okay, but then he kept having this anxiety about work.
--:-- Sean Rameswaram: So he wanted some assurance that when he went back to work after the sabbatical, he would be able to take on some lighter shifts. But his colleagues, the physician group that he worked with, said they couldn't guarantee that.
--:-- Sean Rameswaram: And so I think that triggered something inside of him again. It triggered this, that he was worthless to them. and they didn't really care about him. He started losing his confidence and his skills. He started feeling that maybe he can't go back and be an emergency doctor anymore, and that his career was over.
--:-- Sean Rameswaram: And it didn't end the way that he wanted it, and it ended in a way of he felt like he was shamed and humiliated. And that ruminated in his mind over and over and over again. Scott started to get help at that point for his mental health, and by November, he was diagnosed with PTSD.
--:-- Sean Rameswaram: And one important point is his family says he had no history of mental illness prior to this. But this diagnosis added another layer of worries. So obviously, when you practice medicine, you need a medical license, and these are issued by state boards.
--:-- Sean Rameswaram: And to practice in hospitals like Scott did. You also need hospital credentialing. To get insurance reimbursements, you need to apply for that. And in all these places, doctors can face questions about their mental health and whether they've ever had a diagnosis or treatment for a mental health disorder.
--:-- Sean Rameswaram: He was worried that when it was time to be recredentialed to the hospital or the license that you would have to tell them about your mental health If you've ever had to be on medication, have you ever been admitted? Have you ever had these thoughts that he had? Everything that he was going through, he was worried that he would have to share it with them.
--:-- Sean Rameswaram: And what would they do with that? Would that ruin his career? Would he be done? Scott's condition got worse. He felt more agitated, more angry. He wasn't sleeping. He was depressed. And in early February, he attempted suicide.
--:-- Sean Rameswaram: And he was admitted to the same hospital where he worked, which was a huge point of humiliation for him to be cared for by the colleagues that he basically wanted to hide his struggles from. But because of another quirk in the system in the U.S., doctors' health care is often only covered in the system where they worked, and that includes psychiatric care.
--:-- Sean Rameswaram: So he was admitted there, and he had a really just a terrible experience at the hospital. So he had to go to the hospital where he worked for treatment for his attempted suicide, which came out of work. That's right. That's crazy, right, to force a doctor who is colleagues with all these psychiatrists and regularly admits patients to these wards in the hospital to be forced to have care for himself in that same facility.
--:-- Sean Rameswaram: And it was just tremendously humiliating and stressful for him to be among the colleagues that he wanted to basically hide his struggles from. And after two days, he was discharged. I remember when he was discharged, he looked at his discharge notes and I could just see his face going blank like, this is it. This is it for my career.
--:-- Sean Rameswaram: I'm not going to be able to go back to work. They're not going to let me come back to work. after all of this, was something that I think, in the end, had a lot to do with him taking his life, is that he knew that this career that he worked so hard for was going to be gone.
--:-- Sean Rameswaram: And that it was gone in less than six months. That this is something that took him such long, hard hours, and dedication and sacrificing could be just thrown away for mental illness. He couldn't think of it any other way. Less than two weeks later, Scott Jolly died by suicide at home.
--:-- Sean Rameswaram: How to help our healers in a minute on Today Explained. Support for today's show comes from Adio. What is Adio? Adio is an AI-native customer relationship management system built specifically for the next era of companies.
--:-- Sean Rameswaram: They say it's extremely powerful, adapts to your unique data structures and scales with any business model. According to Adio, Adio takes less than a minute to set up, and within seconds you will have your email and calendars synced.
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--:-- Sean Rameswaram: That's attio.com slash todayexplained. Support for this show comes from Macy's. It's almost fall, and that means it's time to cycle your wardrobe to the cold setting.
--:-- Sean Rameswaram: Because while everyone loves a breezy summer outfit, let's be real, layering is even more fun. That's why Macy's Fall Fashion Guide has everything you need to piece together the perfect look for you.
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--:-- Sean Rameswaram: You can even throw in some textural layers for contrast like a faux fur bomber jacket from Karl Lagerfeld Paris. Whether your old favorite sweater or coat is on its last threads, or you're just craving a new vibe to switch things up, Macy's has got you covered this season.
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--:-- Sean Rameswaram: Beluz you spent months reporting on stories like Scott Jolly which we just heard How big is this problem of mental illness in medicine? It seems to be quite a big problem.
--:-- Sean Rameswaram: So the best estimate we have suggests that doctors die by suicide at at least the same rate as the general population, population, which when you think about it is kind of absurd because they work in the health system, they have access to health care, they know about the importance of treating mental illness, and yet they're dying at at least the same rate as the general population.
--:-- Sean Rameswaram: I talked to the author of that study and she said her estimate is conservative and she cited an upper limit of approximately double the rate of the general population so that they have twice the risk of suicide.
--:-- Sean Rameswaram: Suicide is often referred to as an occupational hazard of the medical profession. And then there are all these barriers to access that make it particularly hard for doctors to get help when they need it.
--:-- Sean Rameswaram: I think in the United States, but also abroad, we just revere people in the medical field so much. Doctors, nurses, they're heroes. They're heroes. And in the case of a lot of doctors, they're handsomely compensated, right? It's a surefire path to having a shiny red convertible or something like that.
--:-- Sean Rameswaram: But what's causing these high rates of mental illness among physicians? So one thing that you just kind of touched on, so they go through a tremendously long training process.
--:-- Sean Rameswaram: So if you've had any friends who are physicians, like by the time you've been at work for a couple of years, usually they're just like starting their residency and then still have years ahead. And that often means they've accumulated a ton of student debt.
--:-- Sean Rameswaram: I was actually surprised to learn that they're struggling with their finances more than you might think, more than the shiny red convertibles would suggest. But putting that aside, they just work tremendously long hours.
--:-- Sean Rameswaram: You go through medical school, which is obviously really demanding, and then you get into a residency program and you can work these 28-hour shifts. that means they're not sleeping. Many of the doctors I spoke to said they just don't eat, particularly in emergency rooms.
--:-- Sean Rameswaram: It can be hard to find a place to basically stop and have some food and drink, so they just go hours without eating. So, you know, switching between day and night shifts, it can often mess up their sleep, which can make them maybe more predisposed to mental health problems.
--:-- Sean Rameswaram: And then going back to something we touched on earlier, this psychology of doctors. These are people who are extraordinary in many ways and demand a lot of themselves. And then when they hit these struggles, it can be really hard to reach out and to acknowledge a problem.
--:-- Sean Rameswaram: And then you put on top of that the fact that they can be professionally punished for it and put on the line everything that they've worked so hard for for all those years.
--:-- Sean Rameswaram: Tell me more about these policies. What's keeping doctors from seeking help? There's this overlapping set of policies, so hospital credentials, insurance reimbursement forms, state medical boards.
--:-- Sean Rameswaram: At all these points in a doctor's professional career, when they're getting licensed or credentialed, they're relicensed or recredentialed, they can hit these questions about their mental health histories, and that also goes for substance use disorders and physical health problems as well.
--:-- Sean Rameswaram: And I think from the point of view of these organizations of the state licensing boards and the hospitals they want to prevent patients being harmed so they want to basically screen for doctors who might have problems that you know could create a medical liability or a malpractice case.
--:-- Sean Rameswaram: And so in a majority of states the licensing boards still ask about mental health and on hospital credentialing forms, apparently it's quite common to have a HIPAA waiver so the hospital can go into your medical record.
--:-- Sean Rameswaram: And so in all these places, yeah, doctors are asked to disclose about any treatments or diagnoses that they've received, in some cases in their entire lives. And so that creates this culture of fear and silence about mental health.
--:-- Sean Rameswaram: I spoke to one psychiatrist who said she just routinely gets requests from doctors not to document their sessions. I talked to doctors who only they only pay out of pocket if they do go to see someone for help.
--:-- Sean Rameswaram: And so they create no insurance record of it. Other doctors said they go out of state for care. Or, of course, they just avoid getting help. It's just a problem on top of a problem.
--:-- Sean Rameswaram: I mean, the situation sounds totally bananas. So we initiate doctors essentially by throwing them into the deep end on these extremely long shifts where they're sleep deprived and aren't eating properly and totally stressed while under debt.
--:-- Sean Rameswaram: And then once they swim out of there, if they make it, they're struck with this next problem, which is that they have to live with this stigma around mental health, which we heard from Scott once he had his attempted suicide.
--:-- Sean Rameswaram: He didn't feel like he could ever go back to being a doctor. What happens when these doctors have problems and do disclose their mental health issues that that they have a problem? It can go hauntingly badly.
--:-- Sean Rameswaram: So I spoke to a doctor named Justin Bullock. I'm a second year resident in internal medicine at the University of California, San Francisco. So he's graduated medical school. He was also at UCSF and now he's a resident there.
--:-- Sean Rameswaram: And Justin is someone who's had a long history of mental illness. It runs in his family. And When he was a teenager, he had his first suicide attempt. And while he was in medical school, he was diagnosed with bipolar disorder, and he had another suicide attempt.
--:-- Sean Rameswaram: But contrary to everything we've talked about before, Justin is kind of an outlier because he's actually outspoken about his mental illness. The medical school has this day called Mental Illness Among Us, where basically four medical students share their experience of mental illness with the first year class.
--:-- Sean Rameswaram: And I really shared something that was very dark and very sort of suicidal sounding. And I just had such a positive response from all my peers and everyone. And I think at this point, I had already sort of I was doing well in medical school already.
--:-- Sean Rameswaram: And I think a lot of people were very surprised because they didn't expect that I was struggling so profoundly with mental illness. So Justin's story kind of flips what we've been hearing on its head. He discloses all these struggles he's had with his mental health and is showered with support.
--:-- Sean Rameswaram: Totally. And I think he liked UCSF and wanted to stay there because it was this inclusive and supportive environment. I had so many people who came up to me and, you know, would share their experiences because I had spoken about my struggle with bipolar disorder.
--:-- Sean Rameswaram: And my mental illness became something that I was able to give back positively to my class. He ultimately excelled there like he had been excelling his whole life, like since he was a teenager.
--:-- Sean Rameswaram: So he got chosen by his peers and faculty to win this big award at graduation for basically embodying the values of a physician. And this was just tremendously validating and confidence inducing for him.
--:-- Sean Rameswaram: And I sort of had the mindset that as long as I'm a good doctor, I'll be protected and people won't stigmatize me for my mental illness. Huh. So what happened after he graduated? So he decides to stay at UCSF where he's had this positive experience as a student, but it was tough.
--:-- Sean Rameswaram: So he's hitting this wall of, you know, impossible shifts with residency where you have to work night shifts and day shifts and they're flipping all the time. And then he has a friend who dies by suicide. At that point, I had been on the path of doing a little bit better. And his suicide really just put me back quite a lot.
--:-- Sean Rameswaram: And it kind of, suicide became like the only thing I was thinking about all the time. And I really like, yeah, it was very challenging for me. And I think I just really never recovered.
--:-- Sean Rameswaram: And in March 2020, he attempted suicide again, and he ended up in the hospital. And just like Scott Jolly, he was treated at the same hospital where he works, which wasn't optimal.
--:-- Sean Rameswaram: And this time, though, he's a doctor and he's no longer a medical student. And when I tried to come back to work I was told that my case had to be reviewed by our institution Physician Wellbeing Committee Physician Wellbeing Committee that sounds nice Yes dystopian nice Needless to say, it was not nice.
--:-- Sean Rameswaram: They really only have one tool that they use, which is something called Fitness for Duty. Fitness for Duty. He basically had to go through this extensive probing evaluation from like drug tests, the personality test.
--:-- Sean Rameswaram: He had to release his medical records from his psychiatrist and therapist. The notes from your therapy sessions, isn't that just between you and a therapist typically? Unless you like murdered someone?
--:-- Sean Rameswaram: So because I was air quote asked to do it, I had to sign my rights away to my medical record. So essentially I gave them permission through this, again, I'm air quoting, voluntary process.
--:-- Sean Rameswaram: Um, so it's not illegal because I signed the forms, although I felt that I was coerced into signing them. So that's important context because UCSF does say that the program is voluntary, but that's a characterization Justin disputes because he says that if he didn't go through the process, his residency might be at risk and he could be at risk of being reported to a medical board.
--:-- Sean Rameswaram: So it sounds like the Physician Wellbeing Committee is not as nice as I thought it was. That's right. Yeah, he even had to meet with an external psychiatrist and have another evaluation, which in his telling was just this atrocious experience.
--:-- Sean Rameswaram: The first day that we met, he said to me, in most patient-provider relationships, I would have your best interest in mind. That is not the case for this clinical setting. I have the best interest of your institution in mind.
--:-- Sean Rameswaram: Yikes. He asked so many profoundly invasive questions. He asked me about my childhood sexual abuse, about physical abuse, all these things. He did not ask me a single question about my workplace performance or anything that happened in the workplace.
--:-- Sean Rameswaram: and for me I felt that if I didn't respond to his questions then I wouldn't be allowed to return to work and I would potentially lose my license and my ability to ever practice medicine ever again and so it was really it it honestly was very traumatizing for me
--:-- Sean Rameswaram: I I have recovered at this point from my suicide attempt I have not recovered from fitness for duty and just to be clear here I mean, to be fair, even, I guess this is all sort of in the name of making sure Justin was fit to treat patients, right? That's right.
--:-- Sean Rameswaram: And this is the thing that's, yeah, so haunting about the story is that he felt like most of the process had no bearing on how he actually practiced as a physician. So in his case, he had glowing reviews consistently from patients and from his colleagues for his entire career, basically, to date.
--:-- Sean Rameswaram: And then, yeah, he's kind of treated in this, what he feels is just an incredibly unfair manner. Did you talk to his employer, UCSF, about this? I asked them. They declined to comment on Justin's case, but they sent a statement saying that the mental health of physicians is an issue that UCSF has taken, quote, very seriously for years, and we will continue to work to improve the support we provide.
--:-- Sean Rameswaram: Even if they do, I mean, as far as I know, a lot of residencies across the United States look like the ones we've described. They're basically stress factories. Where does medicine go from here, at least in the United States? What are the solutions to protect the mental health and well-being of our healers, our doctors?
--:-- Sean Rameswaram: We could start to address the stigma and this culture by taking down some of these barriers to access we've been talking about. And a big one is these ubiquitous questions that doctors face about their mental health. Well, first and foremost, I think it's the culture of medicine.
--:-- Sean Rameswaram: Miles Greenberg, Scott Jolly's best friend. Because a lot of these rules, you know, and questions that come from medical boards, right? A lot of these medical boards, there's a lot of physicians on those boards, right? And so I think a lot of these things come from the old style culture of medicine.
--:-- Sean Rameswaram: And that's the root of the problem in my view. What I heard again and again is that these questions haven't been shown to protect patients. They're not necessarily linked with behavioral issues or, yeah, some form of impairment that might hamper a physician's ability to practice.
--:-- Sean Rameswaram: But they are a deterrent to doctors getting help that could save their lives. And we should stress here that though Scott's story was certainly set in the pandemic that this isn't really new.
--:-- Sean Rameswaram: That's, I think, the most important bottom line. These are long-standing, well-known problems. And we know also that in many cases, these deaths might be prevented. And now we're in this vulnerable moment in the aftermath of the pandemic where a lot of people are kind of coming down from what they've been through in the last year.
--:-- Sean Rameswaram: And they might realize they have a problem and they need help. And in many cases, it might feel like there's nowhere to turn. and so I think if something doesn't change we're going to continue to lose our healers and the people who are caring for us because we're not caring for them and doctors are going to continue to leave the profession or they're going to be forced out or they won't make it.
--:-- Sean Rameswaram: And I think that that's just a huge loss for everyone and Justin is actually great at articulating why. We had a patient who basically had cancer that had spread throughout his entire body. And he basically was crying out and very afraid because he was dying.
--:-- Sean Rameswaram: And essentially, I received a page that I was asking to give him medications to sort of help calm his anxiety. And when I went to go see him, I just sat down with him and held his hand. And as someone who has been very close to dying, personally, I understand that fear, I think, in a way that many people don't.
--:-- Sean Rameswaram: And I just, like, sat with him and, like, held his hand for 45 minutes. And he kind of calmed down. And soon after, he passed. And I would never have done that if I didn't have my bipolar disorder or the experiences that I had.
--:-- Sean Rameswaram: And for me, the way that we help people live is just as important as the way we help people die. And that is informed by my experience with my mental illness. And so no one can ever, ever, ever be able to make me question whether or not my bipolar helps me as a doctor.
--:-- Sean Rameswaram: Because it is profoundly clear the ways in which it does. Our episode today was based on reporting from Vox's Julia Belluz. Her story's got the same title as our episode, The Doctors Are Not Alright. You can find it at Vox.com.
--:-- Sean Rameswaram: If you or someone you know is considering self-harm, please seek help through the National Suicide Prevention Lifeline at 1-800-273-8255. Thank you.
