We're now ready for our keynote speaker, Dr. Pam Weibel, who deserves for sure some background. A little bit about her and a little bit about why I've asked her to talk here today. I do want to note, and you can see up on the slide that we have, that we're going to give Dr. Weibel's talk now. She's also graciously volunteered to be available for a small group discussion, which you can meet. There's going to be a tab on the meeting, main meeting page, after the meeting for several hours. And if anybody wants to talk with her later, you can see there on the slide that she has a website that you can contact her. So I wanted to thank her for doing that. So why we're doing this? Well, in 2017, one of our colleagues, Dr. Dean Lorich, we lost him to suicide. It created a lot of controversy at the hospital. He was a good colleague of all of ours, a very talented trauma surgeon. And we were left asking a lot of questions about why this happened. I started investigating some, as we all did, to see if this ever happened before. And sure enough, I came across Dr. Weibel and her talks and work in the field. And she'd actually investigated a lot of this. And quickly, I realized, listening to some of her own talks, she was already an expert on the subject. And I don't think we talk enough about physician stress, burnout. And then when you start losing colleagues to suicide, I think it warrants discussion. Now, this decision to have her talk was even before everything happened with COVID, because we set this meeting up so far in advance. And it couldn't be any more important to talk about now with the stressors that COVID has brought to us. And I've actually had a patient since that time, since April, commit suicide. And I've also had a father at our girl's school. So it's an important issue. I think the lessons we're going to learn are very applicable to all walks of life. Just a little bit about Dr. Weibel. She came from Philadelphia initially, and was from a family of doctors. Her mother was a psychiatrist, and her father was a pathologist. So I can only imagine the conversations there at dinner. She went to Wellesley College, UT Galveston for medical school, which is why I thought San Antonio would be fitting. But unfortunately, we're not there. And she did her residency in family medicine at the University of Arizona. And she will tell you, and I've read on her bio, that due to a lot of the frustrations and pressure she saw early on, she started asking a lot of questions and trying to get an idea from patients what an ideal clinic would be. She now has her practice in Eugene, Oregon. She's written extensively on the topic of physician suicide. One of the more relevant publications I've seen her publish was Physician Suicide Letters with Answers in 2016. But she's chronicled a lot of these cases. And again, that's why I've asked her to talk tonight. So I hope everybody enjoys the talk. It's going to be followed by a session on physician burnout, which I think is very apropos. And again, you can have a smaller group discussion with her if you'd like, through the meeting page after or even down the line. So I'd like to welcome Dr. Weibel. And thank you so much for talking to us. Okay, welcome to Healing Our Healers, Preventing Physician Suicide. As far as disclosures, I have nothing to disclose. I will be sharing a little bit about how I got into this topic later in the talk. But essentially, I've lost so many of my colleagues to suicide that this has become a personal quest of mine to understand why my colleagues are dying. So I am not funded by any grants or supported by anything other than currently now keynotes to help me continue the work that I'm doing and crunch the data, especially related to certain specialties like orthopedic surgery. And that's what I'll be focusing on today is the suicides of orthopedic surgeons and how to prevent the loss of our future colleagues. I'd like to honor four orthopedic surgeons at the beginning of the talk. This is dedicated to their lives, of course, dedicated to the lives of all doctors that we've lost to suicide. But in particular, I'd like to honor today Dr. Dean Lorich and Dr. Thomas Fischler, as well as Dr. Stephen Ortiz and Dr. Benjamin Schaefer. Because I have a wealth of information about these last two gentlemen, I'm in touch with their family members and they have approved of me sharing this with you all today. I'd like to dive a little bit deeper into why we lost these two wonderful orthopedic surgeons to suicide. And to start with honoring Benjamin Schaefer, just a little bit about him. He, amazing guy, look at the smile, just a great orthopedic surgeon, loved people, 25 years thriving in a D.C. area orthopedic practice. He was the go-to guy in the D.C. area as an orthopedic surgeon. He trained at the University of Florida College of Medicine, did his residency in New York City. He was the chief resident, also then a fellowship at Curl and Jobe. He authored 50 publications and 21 textbook chapters. Plus, I personally, as a family doc, have to say I'm absolutely floored by the fact that his CV is 41 pages long. The guy was a master and just sought out internationally for his brilliance in orthopedic surgery. He was the medical director and team physician for the Washington Wizards, the Nationals, the Congressionals, the National Ballet, an NHL physician for the 2010 Olympics and more. So, very, very amazing person, but also a kind, sensitive soul who loved helping people. So, just the perfect balance of human characteristics that made him a wonderful orthopedic surgeon. And so, just a little bit about him, just so you can see who he was before he got into medicine. So, this is a picture of him in high school. He was voted most likely to succeed. Of course, that has sort of a sad double meaning now, but nobody saw this coming. He was so full of energy and voted most school spirit. And though he had lifelong anxiety, he actually, I don't think many people knew about the anxiety element. As far as what most patients and colleagues saw is just this beautiful smile and this wonderful man always ready to serve. They actually called him Dr. Smiles. And so, you might wonder why does a happy doctor die by suicide? And I want to just go through exactly what led up to his decision to take his own life. He was recently, status post back surgery, was dragging his foot, not able to exercise. He was expected to make a full recovery, but at this time, as we all know, exercise and activity is really important for people. As a mood stabilizer, he was not able to enjoy that normal level of activity. And I think it's really hard for physicians because we place ourselves in such a different realm than our patients. It's hard for us to be ill or to be struggling with what our patients are struggling with. So, I think that was hard for him as well, psychologically and physically. He was also off his anxiolytics for two months, weaned off of benzos. His psychiatrist had then retired and he went to a new psychiatrist who told him he would be on medications the rest of his life, which for him felt like some sort of a death sentence, that he would never be able to be normal off meds. And he was on, by the way, a series of new medications. Obviously, it's very inconvenient to change doctors and to have a new doctor then creating a new treatment plan for you, who doesn't really have the history of your behavior in your life, and you're just establishing with them. And this combination of things led him to feel like a great sense of despair, down to the point of feeling suicidal. And upon talking to his family, a lot of this had to do with just incredible insomnia. Because of weaning off his meds, he was unable to sleep. When you're unable to sleep, you're unable to recover day to day. And so functioning on two or three hours of sleep, that's poor sleep, I'm sure non REM type sleep, he's getting back up and doing surgeries. And probably feeling like he's a danger to his patients even, but afraid to admit that. He feared hospitalization due to stigma and a reputation that he had felt that he needed to manage in the DC area. I mean, everyone looked up to him. So the thought of him being in a psych ward, you know, just I think he just couldn't bear it, even though he knew inside that was probably the right move to make. Instead, sadly, on May 20, 2015, he hanged himself at home. So this is how we lose an amazing orthopedic surgeon. And I just think this can happen to any of us. Under the right circumstances, we're human. And we all suffer, I think, from mental health hits in this profession. Let's just face it, we see people die, we have bad outcomes, we have injury to our perfectionism and our worldview. And, you know, and we all are going to end up being in the hospital one day for one thing or the other falling ill. And so I just think noticing what happened to Ben Shaffer, hopefully, and understanding what happened to him, we can prevent ourselves from going through the same thing or save a colleague. And so I want to talk about the reaction to his suicide. It's very hard for people to understand these are actual real comments from his patients, like on his legacy obituary page, I had come into his office feeling so miserable and left laughing, startling news, you know, obviously, this is before he died, you know, these are the patients that he was, you know, these are just testimonials to how amazing he made his patients feel safe and loved, cared for, and even humored that they were going into surgery, right. So and obviously, here's another one startling news. I was a med school classmate of Ben's his energy and zest for life, but most of us to shame, the smile was contagious, the most charismatic man I've ever encountered. So another quote, I like so many of Dr. Shaffer's patients and devastated at the news of his death. I called yesterday to check on my upcoming appointment with him and was hit with a ton of bricks news. All I can say was what? Oh my god, what? He was so full of life and energy. I think this is why this is so hard to comprehend. So this is an article that I wrote about why happy doctors died by suicide back in 2018 on Medscape that I want to share an excerpt from the article is based on Ben Shaffer's story. I highly recommend that you look it up. It's called Why Happy Doctors Died by Suicide, and happened to be one of their top 10 articles of all of 2018. If that gives you any sense of how necessary this conversation is, I think a lot of people want to talk about mental health and physician mental health, but they just don't know safely how to begin the conversation because again, of the stigma. So I think a lot of people are reading this article sort of, and a lot of the things that I've written on suicide, but you know, in the after people go to bed and sort of in the privacy of their own homes, because this is such a, such a charged topic. But this is a quote that I pulled out of actually an 1858 manual of psychological medicine. I just, I'm going to read it to you. Carlini, a French actor of reputation, a sort of physician to whom he was unknown on account of the attacks of profound melancholy to which he was subject. The doctor, among other things, recommended the diversion of the Italian comedy. For said he, your distemper must be rooted in deed if the acting of the doctor must be rooted in deed, if the acting of the lively Carlini does not remove it. Alas, ejaculated the miserable patient. I am the very Carlini who you recommend me to see. And while I am capable of filling Paris with mirth and laughter, I am myself the dejected victim of melancholy and chagrin. I think this is a quote that a lot of us can relate to because we spend a lot of our time making other people feel well. And sometimes we're not feeling well. And a lot of us are sort of have that jovial exterior, you know, you know, thumbs up, giving thumbs up and high fives and cracking jokes, but we're not really necessarily feeling that way inside. It's like a facade. I think this quote brings up the memory for me of Robin Williams and a lot of people in industries that are, you know, they're looked up to, to entertain and make other people feel well. And there's no real space for us to process our own grief and our own distress. And I think amid COVID, this is even more critical for us to realize that we need downtime. We need debriefing. We need mental health care as medical professionals, and it should be confidential and non-punitive so that we feel safe to receive it. And so, you know, physician suicide is really our public health crisis. It's the pandemic before the pandemic. It impacts 1 million Americans annually lose their doctors to suicide each year. You know, they say approximately 400 doctors die by suicide each year. That's not counting medical students, and that's likely an underestimate. Each one of those doctors cares for 2 to 3,000 patients. If you do the math on that and include medical students, you know, that doctors, you know, students, doctors, and patients consider them their doctors, you know, when they come in in their shorter white coats, sometimes people don't know the difference. You know, that's a lot of patients who are losing the people who are caring for them. And this is an actual woman who contacted me named Susan, who agreed to have her picture published, and she lost her doctor to suicide. And she asked me if her doctor was on my registry, on the list that I maintain, because I've been tracking these doctor suicides for eight years, because I did not see that any external organization was doing this. And again, I wanted to understand why my colleagues were dying by suicide. So I did find her doctor on the list. Her doctor is Dr. Steven Ortiz, the other orthopedic surgeon in that picture in the introduction, and I'm going to share a little bit more about what happened with him. So a wonderful guy, Dr. Ortiz, a very thoughtful, kind, compassionate man. He actually grew up down the road for me in Eugene, Oregon. I didn't know that until after he died, but I became close to his mother after he died and she reached out to me. He originally worked as a sprinkler fitter and worked in construction, which was like the family business. But then he tore his meniscus, ended up at an orthopedic surgeon's office and nearly fainted when the orthopedic surgeon showed him the x-ray, which is kind of funny, and somehow decided that, hey, he was attracted to maybe going into orthopedic surgery himself. So at 28, he got a chemistry degree and then a full ride to Stanford Medical School, full scholarship. But he was a real family man. He never forgot birthdays, holidays, and special occasions, already had kids and such, and was married at the time he went to med school. And the problem is, as many of you know, going through our grueling training, especially if you choose a surgical specialty, you often have to sacrifice your relationships for your career. You don't get to spend as much time with your wife or husband and children and family and hobbies. You know, you sort of, for professional success, end up having what I call personal life atrophy. And so his first marriage failed as a result of this. He was then remarried. He set up a practice in a Florida hospital. I think this was not anywhere he really wanted to practice Florida, but it was where his second wife wanted to settle. So he's such an agreeable guy, has trouble saying no. And he then settled in Florida, where he was adored by patients and staff at the hospital. And it was actually, I love this story. Steve is really the ultimate fix-it guy. And not only is he trying to fix, he's a spine surgeon trying to fix your spine. He also, there were potholes in the hospital parking lot, which he was really upset about. And a lot of the staff and the hospital employees were upset about this, including the patients who needed spine surgery that were bumping up and down in their cars over these potholes. So the hospital apparently was dragging its feet to fix these things. So if you can believe this, Dr. Ortiz arrived to work early one morning and fixed the potholes himself. He was out in the parking lot with cement and however you do it, asphalt. I don't know. He fixed these on his own before heading in to perform surgery on patients. I just want you to understand his character and how much he cared for people. And this is a picture of him with his mother. Stephen was a very ethical man. He refused to withhold care from patients or to perform unnecessary surgeries. And as a result, his income and career were threatened by his employers and his peers, other orthopedic surgeons and specialists at the hospital told him to just go with the flow because this is just the culture here. And he really couldn't bear it any longer. So he did call his mother the night before he killed himself. He actually left a letter disclosing the corruption that he experienced in the hospital. He went in to check on his patients in the hospital and make sure they were okay. And then he went outside and shot himself in the heart in the hospital parking lot where he fixed the potholes. This is really terribly tragic in so many ways. Again, like Ben Schaefer, the brain drain of just losing somebody that's so skilled and not only skilled, but like a loving ethical person who's a physician. It's very hard. And then of course, just the downwind effects on his family and his children. And it's just absolutely something that I don't want to see repeated. So that's why I'm delivering this content because I know if we can empower each other with the truth and with real strategies to prevent these, then we can stop losing our colleagues to suicide. So this is actually the last email he sent before he died. This was given to his nurse. I'm just going to read it. Sorry to leave this up to you, but wanted to say goodbye and thank you to everyone at the hospital. And I'm asking you to say goodbye for me. I really enjoyed working with everyone and truly appreciated everyone's hard work and dedication to my patients. I have some decent offers to stay in the area, but just cannot muster up the energy to change practices again. because of my recruitment agreement, I have to stay in the area until November 2018. If I stay, I won't get referrals from doctors and the practice will continue to struggle. I left my last practice because the surgeons there were doing unnecessary surgery. And now I've landed in a place where I'm coerced to withhold care from patients. Just can't win, I guess. So after all that, I have decided to check out. It was great working with you. Always enjoyed your sense of humor. And of course, appreciated how well you took care of my patients. And another talk I gave actually in Florida, nearby his hospital, his nurse came and actually spoke on stage and shared more details about what this was like for her. And so this is just sort of more collateral damage. All the peers left behind who had to read this email, who knew him and loved him, his nurse, who obviously has his memory ingrained in her heart and soul forever. This is just a scene that I think it's hard for anyone to have to be witness to this or get the last email. And we really need to do our best to prevent this from happening again for so many reasons. In addition to the fact that a million Americans are losing their doctors. So as a little gift to you all today, I'd like to offer a free audio book of physician survival stories. Okay, I know the title sounds really a little creepy and sad, but it's actually very inspirational and validating. I think for physicians who are in pain, this is a book of suicide letters, not suicide notes. These are letters, cause I run a suicide hotline. So these are letters that have gone back and forth between me and a variety of doctors who have considered dying by suicide, with their pros and cons list and processing their pain with me. And in the end they decided not to, right? So this is kind of probably a lot of material that you can relate to that you may have felt yourself. And because some people, they don't really like to tell other peers that they're suicidal or reach out and even call a suicide hotline. I do have the audio book version of this that's free on my website. And it's almost like listening to three hours of a physician suicide hotline or helpline so that you can get validation and support and the comfort of your own home and know that you're not alone. And that there is help. So I'm just offering this all to you today. And again, it's at idealmedicalcare.org. If you click on books, there's a little link for a free download for the audio book. This is actually a wall in my home business office covered with photos of doctors who have died by suicide. They are also medical students. And two of these pictures are of men that I actually dated in medical school who died by suicide. Not while I was dating them, but later at 39 and 44 years old, married with children, apparently leading successful careers as physicians. So again, this hits home for me. It also hits home for me because I was suicidal at one point as a physician. So I have a very personal quest here in wanting to understand why I was suffering and why I've lost so many people to suicide in medicine. So at this point, after eight years of studying this, I have had 1,477 physician suicide cases submitted to me that I have investigated in various ways. Sometimes it's just the autopsy or a newspaper article or speaking to family members. Sometimes I've actually led the eulogies and attended the funerals. So I know quite a lot about many of these cases and I have broken them down. You can see at the bottom out of 1,477 suicides, 1,290 were physicians and 187 were medical students on this list. And these are just organically submitted to me from people who call and email and send me the obituaries and let me know. Sometimes it's the person that was in the same office wanting to let me know their partner hanged himself in the office. So these are reports from colleagues and friends and family usually. So 1,207 of these cases were in the United States and 270 are international. And this is the breakdown between the top level of surgeons. These are just raw numbers. The next slide will make a little bit more sense as to real risk based on specialty. But raw numbers, you can see surgeons are number one, anesthesia number two. And then as you say, these are just the major specialties. I also have people in nuclear medicine and immunology and other sort of minor specialties. They're not included on this graph because the graph would be way too large for the page. But I wanted to focus on surgeons today and show you this next slide, which really breaks it down by active physicians per specialty. So if you take the number of cases I've received and really kind of do a calculation based on the numbers in each specialty, because let's just face it, there's a lot fewer radiologists than family docs. So if you kind of do a calculation, you can see that essentially anesthesiologist risk is about, turns out 1.9 times as high as surgeons, which is the second leading specialty as far as suicide risk and 6.5 times as great as pediatricians. So there is definitely a higher risk of suicide in certain specialties. And this is not like written in stone. This is just based on my calculations from the first 1,477 cases I've received, but I think it gives us a great view into what is very likely going on and would be confirmed by other data if we were to be able to actually get other data. This is such a taboo topic. It's hard to get this data. So the reason why the top five always tend to be, sometimes psych is lower than OBGYN when I do these calculations. It has been in other graphs that I've presented, but anesthesia surgery and EM are always at the top. So, and psych and OBGYN, let's just look at those five. So obviously in these five categories, there's a lot of exposure to trauma and unexpected trauma and what I would call vicarious trauma, meaning like, so I'm family medicine and I don't feel very traumatized when I do pap smears and ingrown toenails. I can tell you acne, asthma, like I'm just doing bread and butter type family medicine and I don't find myself feeling traumatized, but I can tell you anesthesiologists and surgeons, emergency docs, OBGYN, when you have an unexpected maternal death, when you have a stillborn, when you are dealing with a car accident and a dead teenager, you're having trauma exposure that I'm not having. And I think that is what elevates your risk in these categories. And as well as of course anesthesia, they have access to painless legal means like 24 seven. Of course, we all could probably find some painless legal means if we wanted to, but the ease of access is a huge element that raises the rate among anesthesiologists. So moving along, oh, and of course, psychiatry, they're not necessarily exposed to hands in the belly or procedural trauma, but they're hearing terrible stories about incest, people being murdered in somebody's family, they're hearing homicide, suicide stories and all sorts of things which are childhood abuse. And so I think that affects them the same way that actually experiencing the real trauma that surgeons hear and that are procedurally actually experiencing. The sensory experience of having your hands in somebody's body or near somebody's body when they die and witnessing their last breath and all of that, that should traumatize you if you're a human being. So next is just a list of some of the things I've learned that since researching this is that we've had high doctor suicide rates reported since 1858. So we've known about this for a long time. It just has not been on dinner table conversation, been a taboo topic. Top rated beloved doctors are dying by suicide. The censorship that we have experienced on this topic actually leads to more doctor suicides because we're not actually debriefing after these cases. So we're not really understanding. There's a lot of doctors walking around who've lost colleagues to suicide who have no idea why their colleagues died by suicide. And it just leaves a lot of unanswered questions and leaves us, I believe, at risk with a lack of understanding why this happens to lose more. Methods do vary by region, gender and specialty. Doctors do develop occupationally induced PTSD, anxiety, depression and suicidality and personal problems are definitely fueled by professional demands. Because sometimes they'll say, oh, well, he was in the middle of a divorce. That's why he died. Okay, but why was he in the middle of a divorce? Because you're working 100 hours a week and three different hospitals on call all the time. You can't just really blame it on personal life issues because your profession has taken so much time out of your personal life that we really have to look at this with a wide lens. So these are surgeon suicides by subspecialty. And I just want you to see that orthopedic surgeons are the number one group as far as raw numbers that I received, 55 orthopedic surgeon suicides that I'm going to actually review today with you. And here's the list of the other general surgeon ophthalmology euro. You can see the list here. I've also made this available as a PDF handout. So hopefully you can, if you'd like to sort of stare at this data longer, you can afterwards hopefully download that handout and review this on your own. These are, again, I'm going to review some of these 55 orthopedic surgeon suicides. Of note, I delivered this, a very similar talk two years ago at an orthopedic surgery conference. And at that time, I only had 33 orthopedic surgeon suicides. So I've received 22 more in the last two years. So this is really important to notice. A review of the cases, you can see that six are residents, 49 are actual orthopedic surgeons, and 45 are in the US, 10 international. The international cases, more of them always tend to be in India because India does not censor this topic as much as other countries. So you can actually see newspaper articles in India online. And in fact, in India, they have a very interesting law on the books called abetment to suicide, which allows you to actually face criminal charges if you've harassed somebody and been named in their suicide notes, and they actually will take you down to the police station and interview you for having encouraged somebody's suicide or set up a situation in which you made it impossible for them to work safely in their job because of harassment or retaliation or whatever it is. So I think that's why India has more of us, maybe just a greater population there as well. And if you look at the male versus female, basically I had about 54 male surgeons when I was putting this male orthopedic surgeon, when I was putting this talk together and at the midnight hour, before actually finishing up my talk, I actually had a woman contact me to let me know that a female orthopedic surgeon had died by suicide this past April. And so she is added to the list. So we now have our first female orthopedic surgeon suicide that I'm aware of. There may be others, but as you all know, this is a very male-dominated profession and suicide is a very male-dominated condition. Generally, men are dying by suicide at a far greater rate than women across the board in all professions and in the general public. I think probably a three to one ratio, maybe in the general public. Don't quote me on that, but it's in that range. In the medical profession, I find for every one woman that dies by suicide, we lose four men to suicide. So this is the age of the orthopedic surgeons at suicide. So they're obviously kind of peaking around 40s or 50s, I would say. And this is the dates of the suicides. So I've been working on this since October 28th, 2012, when I left the third funeral for a physician that died by suicide in my town. Within a year and a half, I started tracking this because I just was alarmed by the sheer volume of cases that I was hearing about. And by the way, when I was suicidal, I actually thought I was the only doctor that was suicidal on the planet. It was 2004, I had no idea that other doctors suffered with this, with these feelings. So again, validation, this is common. I think a lot of doctors have experienced disillusionment, depression, anxiety, suicidal ideation. Since I started tracking this in 2012, obviously most of the cases that I have are 2012 and beyond. Although people do call to submit cases, I even have two cases that have been submitted to me from the late 1800s with obituaries. So this has been going on for a while. It's just that most of my data is more recent. And these are the methods that orthopedic surgeons tend to use when they die by suicide. So 18 are gunshot wounds, 15 are unknown, which is very common not to know because there's so much secrecy around these deaths that it's hard to know. Even if you're a colleague, you don't know what happened. Overdose eight, hanging six, and then we've got a tie for the last four and stabbing, cutting wrist, jumping and drowning. Okay, so by the way, the two of these cases of the orthopedic surgeon suicides that were suicide homicides involved the husband's wife and all the gunshot wounds were in the United States. So here is a review of the primary cause because everyone wants to know, I think that's the big question afterwards, why did it happen? And I can guarantee you it was multifactorial. However, the straw that broke the camel's back, so to speak, the last thing that sort of put them over the edge tended to be in this breakdown. And I'm gonna go through each of these in a little bit more detail. So mental illness, the stigma of admitting mental illness is the number one problem we face in medicine. Then marital distress, unknown, medical system, medical error, retirement, hospital corruption. Some people find that they're in the wrong career and they really weren't even meant for medicine or orthopedic surgery, but then feel trapped, losing a job, isolation, bullying, illegal activity, financial issues and physical illness. I'm gonna review these in a little more detail with some quotes. These are actual reasons why these 55 orthopedic surgeons, I'm not outing who they are because, these cases are sort of confidential and I have to get family approval before sharing, right? But these are the general reasons why each of these 55 people died. So one was bipolar, hit his mania as enthusiasm. Underestimated the severity of chronic depression and bipolar, so never sought treatment. Untreated depression, this is actually a physician wife who wrote an article about her orthopedic surgeon husband's suicide. He was resistant to seeking care he needed, she reported. Again, the stigma. Insomnia, abusing drugs to keep himself sharp, lonely, kind, happy doctor with untreated depression. Bipolar, never treated domestic violence and drugs. Depression, fear of seeking help as a perfectionist after his job fell through, felt like a failure. Insomnia, anxiety, exacerbation, fear of psych, hospitalization and depression and rage due to stress. So this is the number one category, okay? Marital distress, controlling a mid-failed marriage. This was the murder-suicide of a wife. I believe it was an Anna. The next one is the anesthesiologist's wife in a murder-suicide. So both of it, the other wife was a professor actually, but not in medicine. Here's a quote, happy guy, great surgeon, marital distress and a divorce. I even discussed with him your talk, that previous orthopedic surgery, suicide prevention talk I gave two years ago and not surprisingly, he was a leader in our physician community in many areas, including physician wellness. So this is somebody who had seen my talk and was a leader in his community and physician wellness and still succumb to physician suicide. Well-loved spine surgeon, newly in practice with spousal infidelity, a lack of joy in marriage and work, classic happy doctor, rumored divorcing his high school sweetheart wife. Wife left him just after residency and he was never the same. Recently retired and marriage failing. So I think we can all see that any of these things could happen to any of us. We could end up in a situation where we end up retired and in a not so great marriage or infidelity, or this takes a hit on human beings who have feelings. The medical system, as you all know, can create a certain amount of rage and frustration. Here's a retired doctor who disliked his electronic medical record. He disliked the hospital system and regretted going to medical school. Overworked with a 36-hour COVID shift and marital issues. Another with a savior complex, overextending himself for others, feeling tortured and unable to fix everyone. And the system failure really, really impacted him. And of course, another with work issues. This is an example of a Wayne Gunkel. He died due to system-related issues. This is by his daughter, who has agreed for me to share this, who told me that his letter, his suicide note basically said, I'm sorry, I couldn't fix everyone. He had a people-pleaser personality. The medical culture was something he was frustrated with, though. Hip implants he did that were then recalled. Hospital drama and politics. Managing medicine as a business when it's personal and life and death issues, it all affected him. Insurance companies should not be in control. It's stressful getting the approval to do a damn surgery in the first place. If you don't get it, the person may die. You might get sued. Totally messed up. This is coming from his daughter, who also shares he was basically dictating alone on a Sunday morning. He had bought the rope that morning on his way in. Must have planned to finish dictating, but didn't get through it. Stopped abruptly and did it. The note was very short. Basically said, sorry for all the patients I couldn't help. Maybe two sentences if I remember the rest. The first line is what sticks with her mind. And she wanted to also share, because I asked her, what would you share with a group of orthopedic surgeons? What advice would you have? She says, I would want every orthopedic surgeon to know the conflicting thoughts, emotions, and level of stress they deal with. Days of absolute chaos is something I understand and dealt with as a child of a physician. There was a day he stood alone in his closet, could not dress himself. My mom had to go in and dress him and snap him out of it. Calls at every hour of the day and night. Being on alert at all times. Even sitting in church's beeper would go off. And finally, it sounds like he had lost a patient on Christmas Eve and had a total meltdown on Christmas morning in front of his four kids. So, and of course there's parking tickets and all sorts of other, we almost lost his driver's license. You know, just having to rush to the hospital all hours of the night. So, medical errors. I just wanted to share an actual example of system failure and how the system can lead to Wayne Dunkle's suicide. Medical error, of course, you know, people have self-doubt after a few bad surgical outcomes and the peer review. Here's a perfectionist who had a patient complication from a medical mistake as a PGY-3, insensitive, attending, self-doubt, and then stepped off the eighth floor of a teaching hospital while on call. A minor medical mistake and a perfectionist who could not deal with a tarnished reputation and then, of course, a major at-fault malpractice case that he knew he would lose. His reputation was everything. Retirement is not that easy. Depression and retirement. He strongly identified with being a surgeon. That was his life. His physical body just couldn't keep pace with his schedule. Retirement, depression, lack of purpose, pressure to sell his practice to a health system by his wife and partner. What use am I in retirement? Hospital corruption. Failed the oral boards, overworked in a toxic workplace, and pending divorce. Whistleblower. This is Stephen Ortiz for a hospital that's corrupt. A hospital corruption and toxic workplace as a new doctor. I believe that one was Australia or New Zealand. Wrong career. Family pressure to be a doctor. Medical career was a mistake. Disliked medicine. Was sort of a partier and depressed. Disillusionment with career. Job loss. Loss of hospital privileges. Accused of sexual harassment. Led to acute depression and killed himself a few days later. This is a great person accused of sexual harassment of a nurse. Hospital legal counsel recommended termination and then he shot himself. This was actually a really great guy who didn't really harm anyone. I think he was just, I think he was insistent about wanting to date a nurse. And then it ended in this. I mean, really, I feel like this can handle differently. His license suspended for over prescribing pain meds nine months prior to a suicide. Isolation. Overwhelmed without family or peer support and early career. An ortho resident transferred to a new program with an unclear issue. And a beloved happy surgeon divorced years ago. Mom recently diagnosed with stage four cancer. Bullying. That's an issue as well. The one that I can't get out of my mind is this orthopedics intern who was a type one diabetic and attending said he'll never make it with diabetes and he went home and shot himself a few days into residency. I think it's really important for us to understand that our words matter. Things that we say in passing to trainees, they really take to heart. And we could lead somebody over a precipice, right? Illegal activity. Obviously, you know, if you're in trouble getting arrested on charges of prostitution, of domestic violence, you're abusive, you know, this is not going to bode well. Another one molested male high school students, then interns and shot himself as police raided his home. Financial issues. This gentleman couldn't afford to retire. And so he had to keep working. And I think that created distress, debt, and then physical illness. You know, a year after head injury, an orthopedic surgeon killed himself in front of his family. Another had a mild stroke and lost dexterity in his arm and couldn't operate. So essentially, if you were to look at this, 32 of these are primarily professional reasons. 17 are personal, although still I would suggest that most personal issues are having heavy influence from professional life issues. And so most are multifactorial. Most are preventable. I think doctors don't want to die by suicide. They just want their pain to end. And most are impulsive. I've interviewed a number of doctors who survived their suicide. I asked them how long between that when they sort of lifted up, you know, when they decided to kill themselves and took the pills or slice their artery and most said three to five minutes. So it does take heroics to stop somebody from dying by suicide if we wait till the last hour or the last minute. So what I am suggesting we do today is get ahead of this with solutions. And the number one solution is to remove mental health questions from medical licensing applications. Because I think you all see these applications in which you are afraid to check the yes box on hospital credentialing forms to get your state license renewed. Many, many states are still asking these questions. And notice the questions are, have you ever? So it definitely is a huge deterrent for us as wanting to be honest on our applications to admitting that we have bipolar depression or any of these issues. And so what we need to do is replace all impairment questions with, you know, this is what they're aiming for. These mental health questions, they want to know if you're impaired, if you're safe to practice medicine. And I think they have no right to really be asking these ADA noncompliant questions. What we really need to focus on is impairment. And the impairment question that would be much more appropriate to ask is, do you currently have a condition that impairs your ability to practice medicine safely? And so I did a research project on this. If anyone's interested to see where all the states rank as far as what questions they're using, you can just look up physician friendly states for mental health, a review of medical boards on my website. Connecticut, Hawaii, Michigan and New York are the most physician friendly states. They have no mental health or impairment questions. And Alaska is the least friendly with 25 yes or no mental health questions. And so it's very easy to remove these questions, at least from hospital credentialing forms. This is an example. I won't read the whole thing, but there was a peer reference being asked of an anesthesiologist of a peer. And on there, he found a have you ever mental health question. He wrote them and said that this was a deterrent to seeking mental health care. And surprisingly, he says a couple of weeks later, I received an email noting my concern. He explained it to them and actually removed the question. So it's not that hard to get these questions removed. If you bring it up and you ask them to be removed, they are illegal and they should not be on hospital credentialing forms or medical board applications. We also I would like to encourage non punitive confidential mental health care for all physicians. I go to I go to therapy every week. It's awesome. I think we all see so much tragedy. It's very important that we have safe, accessible mental health care to be well adjusted human beings. Most of us enter medicine as humanitarians with noble intentions. In order to be well, we really need to take care of our mental health and and not just talk to our wives or husbands. And I think we need professional professional help, but it needs to be confidential, because how can we really give patients the care that we've never received? And so this is to close. I'm going to close here in a minute. This is a quote that I think is really important. Physicians are treated as criminals track more closely than level three sex offenders, reports a surgeon answering all these questions on applications, a subtle unspoken lesson is you better be squeaky clean mentally, morally and physically. If you step off the shining path, bad things will occur. I have known seven male physicians who died by suicide, most with a happy exterior. Why? They cannot confide in colleagues for fear that their colleagues will turn them into hospitals and boards, as you saw above in a peer reference. And there goes their privileges and livelihood. They cannot confide in their spouses because during rough patches mentally, their marriages are already in trouble. If they share psychological problems, they probably fear that the wife may use this as ammunition in any future divorce. So they keep on smiling right up to the hour they die. So one other thing that has been proven to actually prevent physician suicide that does not require really any effort or money on your part is just sharing appreciation. I think this is something that comes easy to us if we just open our hearts to do this. This picture by the way is on a bridge I believe in Europe somewhere, where a lot of people have died by suicide by stepping off this bridge. This teenager had gone to the bridge to die by suicide and then turned around decided not to. The next day or so, she put these little laminated cards on the bridge as notes to people who were considering jumping. And 17 people contacted her to thank her for preventing their suicides, just with these little laminated notes, which are just reminders that you're loved and you're appreciated, essentially. So anonymous letters of appreciation are always going to be helpful. Authentic, targeted letters of gratitude to your peers will really help prevent suicide, as well as thank-you cards from patients, because patients are often asking me, well what can I do? Just sending a thank-you card of appreciation to your doctor makes an immense difference in their lives. This is from a male psychiatrist. Having practiced medicine for 45 years, I was always, I always, I can't see the whole thing, I always, oh my gosh, thanked. I always loved it when patients thanked me. It was more satisfying than the money I earned. Thank-you notes and letters really help. And this is a final slide that I think is most important, but it's actually a real, a real note that saved the life of a male ENT doctor. He said, here is the text that prevented my suicide. This came from, I believe, a resident. Hey, I'm so sorry about your patient. That sucks. I'm very thankful that we have you as an excellent otolaryngologist to learn from. You have taken care of so many sick patients and do a marvelous job educating us how to do it safely, skillfully, and compassionately well. Thank you for that. It's been a particularly hard year for me, but I'm surviving. Thanks for all you do, Pamela. So I just, I just need everyone to understand that sending one or two sentences by text to a peer and thanking them can actually save their life, really can. It saved this, this surgeon's life. And I have one final request before the end of the talk. So here's a picture of me, almost in the same outfit here. This is kind of how I look a lot of the time, but here's a picture of me when I was suicidal. I don't think we often see the pictures of suicidal doctors. I couldn't get out of bed for six weeks. It was 2004, and it was due to career disillusionment, feeling trapped, practicing assembly line medicine, and wanting to be a real doctor, and couldn't stand being any seven-minute office visits. And so I think it's really important to see what a suicidal doctor looks like, because we seem to be wearing a mask. And if we wear the mask, and we never take it off, and we die in isolation with this sort of look on our face, how can anyone help us? This is what leads to so much confusion. As you'll see, these are beautiful men who are smiling, but they're all deceased. And I don't think anyone got to see them when they were suffering, because they didn't feel safe to share their pain. And so what I'm asking, as a favor to me, and hopefully to each other, and to yourself, is that you'll at least, at minimum, send a text of appreciation to the doctors who have helped you in your life, and in your career, and maybe get in the habit of doing this, and maybe even write a thank-you card. You know, maybe keep in your... I always recommend keeping your white coat pocket some just sort of generic thank-you cards, where you can write just one or two sentences thanking another doctor for something that they did that you witnessed. And what would be even more courageous than that, would be finding somebody, maybe in the same specialty, because I think there is a camaraderie that exists in the same specialty. You know, like I understand family docs pretty well, but I'm not a trauma surgeon, and I've had trauma surgeons reach out to me on the suicide helpline, and I really feel like, wow, it would be so great if they could speak to another trauma surgeon who had survived suicide, or could help them understand the unique factors that trauma surgeons deal with, right? So, you might find another friend in your specialty, a colleague, who you can befriend, and just notice it's hard for other people to go first and share their suffering. Like, if you ask them, how are you doing, even if you sense that they're having a problem, I think it's hard for other people to share first, so why don't you go first? If you were to go first and share some problem that you've had with your mental health during your career, could even be test anxiety in med school, or that you failed a board exam, or that you also maybe had a malpractice case at one point, and started having panic attacks, or had to get, you know, treatment. I think if we start sharing this as normal conversation, so it's not taboo, you know, with somebody that you feel safe with in your career, they will then probably feel safe to open up to you and share that they might be on antidepressants, or struggling, or maybe drinking a few extra glasses of wine after work, and that, you know, maybe we can have less maladaptive coping strategies that exist in isolation, and really come together as comrades and brothers and sisters in medicine. So, thank you very much for listening, and please know that I'm here if anyone wants to reach out individually at idealmedicalcare.org. I return every email and every phone call. Thank you so much. Okay, Pam, thank you so much for your talk, and for spending time with us. It's really a topic that I think we don't talk about enough, and sometimes I think we're afraid to, but I've learned so much from you. I do want to say real quick that I wanted to thank Stryker for supporting this keynote talk. Stryker's been a big supporter of the Foot & Ankle Society in general, and generally supports our humanitarian trip to Vietnam. Of course, that didn't happen, and they were gracious enough to use those funds to help support the talk tonight, so a special thank you. Also, and I mentioned this before, but just to reiterate, and I've got some notes here, but Dr. Weibel has got an additional small Zoom group that you can go to for the next several hours, even, if there's people that would like to talk to her individually, and we just were talking backstage, and she's more than happy to do that. Again, to go to that, you have to go to the list of the sessions from today, and there's a session under, it's a Zoom session under Keynote Physician Suicide Prevention, so go to that if you'd like. It's not recorded, and it's completely private and confidential, and she mentioned to me that you can use that to share any feelings that you have, or even to help process the loss of a colleague or friend that you might have had, and also in the chat function, we've got a couple questions here, but those can be completely anonymous, so I don't want anybody to feel like they can't share for fear of being identified, and then later, Dr. Weibel shared, and I hope we'll show again, but on her website, she takes free support calls when you need, so that's something that would be available even down the line, so again, thank you again. So I wanted to start real quick. We have about five minutes, but one of the questions that came through the chat session, so one of our members noted that physicians will not seek help for mental health or addictions when it is no longer private and has to be reported to every hospital, insurance company, etc., and that they believe that requirement is a major reason why most physicians do not seek help. When it comes to HIPAA, we have, and when it comes to licensing hospitals, etc., where are our rights, and so I'll let you comment on that. I know that's something you did talk about later in the talk, but what is your take on that? Yeah, I think it's really, really simple to remove these questions from hospital credentialing forms. If you let, you know, the chief of staff or the hospital board know that this is actually a deterrent for your physicians getting the mental health care they need, the hospitals have taken these questions off, like, immediately, so I just think part of this is we need to speak up and let people know within our local communities and our medical communities and hospitals, you know, medical societies and such, that these questions are a deterrent and they can be removed immediately, so just speak up. I want to encourage everyone to be empowered around this topic and to defend your rights. Yeah, something we were talking about backstage, too, is, um, it just occurred to me, the topic, like I said, is taboo. Is there an easier way to talk about this, or you're mentioning even, like, different terminology or words that we might use to make it easier to talk about our process? Yeah, three simple things that you can do is just, like, high blood pressure, diabetes, any other condition, just speak about it. Without stigma, meaning don't use committed suicide, because that sort of sounds like it's a crime, like committed burglary, rape, or whatever, like, just say died by or died of suicide, like we would say died of a car accident, pulmonary embolist, or whatever, right? And then also use the term, if somebody has died by suicide, that it was a completed suicide, not a successful suicide, because it's not a success when you lose your orthopedic surgery colleague to suicide. And then, if it's an attempt, you know, use attempt, not failed suicide, you know, because I think when we start using committed, failed, and successful, we kind of overlay a lot of emotions on it and almost blame the victim, and that makes it harder for us to talk about it, like we would talk about, factually, any other medical condition. How about, just based on your research, what are the things that, can you think that we can do as individuals or as hospitals? You know, one thing you mentioned before is work hours, and maybe a maintenance plan, but what things specifically you think we can do right off the bat to help with this topic? Well, the number one thing is to just remove those questions and make it safe for people to ask for help. I look at mental health, like dental health, and I think everyone's on pretty much a dental health maintenance program, or your teeth would not be in your mouth, you'd have dentures or something. So we all need to, you know, firefighters, police officers, you know, physicians, especially surgeons, or anyone dealing with trauma needs to have, you know, a mental health maintenance program. That could be speaking to your pastor once a week, that could be having, you know, a therapist off the grid with paper charts not on the cloud, you know, that could be talking to me or creating a peer support group, you know, just among orthopedic surgeons, I think those things, and I think I did talk about the value of appreciation in the talk, just just texting each other and saying, Hey, you did a great job on that case. And I really appreciate how you helped out or, you know, just a text can actually save somebody's life. So really important also not to put all this on your spouse, you will wear out, you can't rely on your spouse or children for your dental health or your mental health, you know, like really professional help. Just like you offer to your patients with ankle and foot injuries, I think we need professional emotional help, because this is a high risk profession. Maybe one last question to just being a patient. Um, you know, I mentioned I had a patient in April that committed suicide. How do you think you can apply what you've learned and studied to even our patients? And how might that relationship be easier, better or harder? Yeah, I think your patients see you as like a trustworthy person that can help them. And if you open an avenue for communication by just saying, Hey, how are things going at home? Or how are things going with COVID? Or you know, how are you really doing with your injury? If you open that door, you know, they'll, they'll follow through. And they'll, you just have to a lot and probably a longer session for that visit, because they could start really sharing with you a depth of their feelings. I think people are really almost like dying to share their feelings with each other. They just don't know how, because it hasn't been normal in our culture to do so, especially among surgeons. And I think if we just start doing it, the culture of medicine can change dramatically and can save each other's lives. Well, thank you so much, Pam. It was wonderful. It's something that's so important, a nice change for us to be really talking about things that we don't talk about.

Dr. Pam Weibel

physician

suicide prevention

mental health

stigma

medical licensing

confidential care

appreciation

support