Good evening. On behalf of AOFAS, I want to welcome you to the second installment of the 2020 Physician Wellness Series webinar presented in collaboration with the Ruth Jackson Orthopedic Society. Tonight's program, Physician Suicide, will be moderated by Dr. Marlene DeMaio. Joining Dr. DeMaio is Dr. Edward McDivitt and Dr. Lois Swishner. You can find their full biographies and disclosures in the program document posted in the PRC. The 2020 Physician Wellness Series webinars are provided free to AOFAS, RJOS, and JRGOS members with funding by the Orthopedic Foot and Ankle Foundation, supported by grants from Wright Medical Group NV. I'd like to run through a few housekeeping items before we kick off the presentations. Please make sure your speakers are turned on and that the volume is turned up. For technical assistance, you can reference the help tab at any time. 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Here we go. Thank you. Good evening and welcome to tonight's webinar on physician suicide. After our session, we hope that you will commit to act. This session is part of a wellness series begun last year sponsored by Wright Medical with their generous support as well as our friends at AOFAS. And this collaboration has been really spearheaded by past president Alexa Page and our AOFAS ambassador. One of the important disclosures tonight besides our usual academy ones that we review is the Hahnemann-Drexel connection. I want you to know up front that Dr. McDivitt and I were graduates of Drexel when in the last century it was still Hahnemann. And Dr. Swisher, who we're so delighted is here this evening, did her emergency medicine residency there. And she is affiliated with them. Our knowledgeable and insightful speakers tonight have been touched by tonight's topics in different ways. And I know that once you hear their stories, you'll be dedicated to this topic to help yourself and others. Eddie McDivitt I met when I was in the Navy and he was at the Naval Academy doing a great job as the head team physician. And he tackled those really tough issues that many sports surgeons, let alone other surgeons really and medical doctors did not have the ability to talk about then. Substance abuse and even at that time suicide. He's continued his commitment and I'm so thrilled that he did that when I was at the Naval Academy by volunteering for women's basketball, not just any basketball, mind you, but women's basketball. He served as a consultant to the U.S. Capitol. He is an active in private practice. He is really the ultimate orthopedic surgeon. And I truly mean that he is a gentleman. He is a scholar and he is highly respected. And he's had years of thinking about this topic that so many people really don't want to talk to him about. And so I was thrilled that he would be speaking to us tonight. Dr. Swisher is vice chair of the Resilience Committee for the Accord for the Emergency Medicine Residency. She is chair of AMWA for Women in Emergency Medicine. You're going to hear tonight about her personal journey with this topic and her family and of course how it impacted her and those around you. And I know that you will see that her insight and empathy is genuine and she can help us to help ourselves and other people. This seminar came out of one of our previous sessions which was on burnout. That one was with Drs. Casey Humberd and Karen Sutton and myself where we touched a little bit on suicide. And you'll hear tonight, unfortunately it's increasing. There's things that are going on now with the pandemic and isolation and stress and other risk factors. Dr. Swisher is going to help us identify some things to help us be more resilient. But I do want to address before we get Dr. McDevitt going is that there's a lot of people out there including Professor Duckworth and other highly respected professionals that have this idea about resilience and being gritty. I just want to say that I know orthopedic surgeons who are some of the most gritty and resilient people I've ever met and people can be broken and have parts of them broken. We're going to hear tonight the way to manage that because we want you to be happy and we want you to have a great career. So we're going to turn it over to Dr. McDevitt. You can see the National Physician Support Line there. It's a special line just for docs that are having some crisis perhaps. And then we'll take some questions and then we'll go to Dr. Swisher. And we're just switching right over there. Okay, Dr. McDevitt, you're on. Thanks Marlene and thanks for both societies for taking on this tough topic. My next slide has my disclosures and my disclosures have nothing to do with this talk. But my next slide is really important on why I feel I had to be here tonight. And that's because I lost a friend. I thought I was a good friend. He had a lot of things going on. He had a malpractice case. He had some marital problems. He had some medical things. And I said, well, everybody's got a malpractice case. He's one of the top doctors in the country. He's a good looking, rich, perfect guy. He's got a nice family. It'll work out. And I didn't do anything to help him. And he felt things were so bad that he committed suicide as his kids found him. So it was a horrible, horrible thing. And I knew that I had to look at myself and say, what did I do wrong here? And I wanted to learn more about physician suicide and try to talk about it and try to help other people that are struggling. You know, I think a lot of us are on our own little silo. I certainly was in my private practice. I have my own little set of people that work for me and my patients and my other partners were in their own little silo. And sometimes we don't have many people in that little silo. We sort of keep our ourselves protected in that silo. And when something bad happens, sometimes we kick out the people that are in that silo instead of getting them to help us. And then the walls of that silo start closing in on you. And then you get to a spot where you're so desperate. You think the best thing for everybody else is just to end your life. And if we can remember anything from my talk is that when you have trouble, you got to go outside and ask some people to help you. And if you have friends that are going through some tough times, like all of us do, all of us have tough things. Be a good friend, be better than I was and try to help them and be with them. And not just say, if you need me, call me. You got to be there. You got to actually be with those people. Next slide, please. Now we know it's a terrible thing as Marlene said, and it's probably underreported. I think people die by suicide and they say, well, they die by natural causes. And medical students, a lot of these suicide talks are not included in the numbers. And that's a big concern because 25% of medical students report depression, 10% considered suicide. So we got to help our medical students. Next slide. And we have to act. We have to do something. I just can't wait like I did. We have to recognize that there is physician distress. We have to recognize the signs and symptoms of potential physician suicide. We don't think it's going to happen, but it is happening. And what are the steps we must do to recognize a significantly distressed colleague and make a difference and learn from others? Next. And I hope people know about Pamela Wibble. She has made it her life's work to talk about physician suicide. And she said, you know, it wasn't something new back in the 19th century, doctors were killing themselves. And it's now a public health crisis. And most of us have lost several colleagues in Annapolis. I've lost three of my friends in Annapolis suicide. And there's more men that died by suicide than women. And really methods vary by the region, by the sex and by your specialty. And male anesthesiologists are at the highest risk. But happy doctors die by suicide. My friend looked like to be a very happy, successful doctor, and I missed it. Next slide. And why die by suicide? It's almost always untreated depression and medication can be a helpful life saving thing for you. But you know, one of the things about depression is that when you're depressed, your immunity is depressed. So a lot of things we do to try to improve our immunity with our, you know, fighting all the things that are happening, like exercising and getting some sleep and having friends and being nice to other people can be helpful. So medicine is great, but also being kind to other people is something we really should try to do more of. Next slide. You know, if you made it to medical school, and I had a hard time getting to medical school, I was not like the superstar college student. But I really felt that I won the lottery, right? I was so happy that I got into medical school. But a lot of people that are there, they've always been the top of their class. They've made it to a great college, they've made it into medical school. And maybe they found a really good residency, maybe even better fellowship. But somehow they get there and they say, is this it? You know, and they see all the tough things that are happening, and they get some burnout. And I found it fascinating that Freudenberger years ago in the 20th century, described burnout, but he described it for childcare workers, not doctors, but really, for all of us that have children and trying to do our job and trying to take care of our children, and trying to find that work life balance. How do you do that? How do you do everything and do everything well? It's not easy. Next slide. And you know, Marlene and I are military people, so you know, we love Dilbert. And you know, welcome to Dogworth's seminar on white glove balance. Let's review your list, your priorities, family, job, exercise, vacation, must do, medical, eating, hygiene, sleep, romance, holidays. Now you have time for three things, work and holidays are two, pick the third. So how do we get through our lives when there's so much stuff, so many things on our agenda? Next slide. Not many people are like binging, like I am Netflix, you know, when they have time, and I've been watching this TV show Borgen. Now Borgen is about the first, it's a fictional story about the first Danish female prime minister. And she's so excited to get that job. And she's trying to do everything she can as a prime minister, taking a lot of her thing, but she's also trying to figure out how to work that balance. She wants to be there for her husband, she wants to be there for her children. She wants to have time for herself. But guess what? She shows to the public, this big smiling face, she's always got this beautiful smile. But in that show, we see behind the scenes, her crying in desperation, her husband leaves her, one of her children has to go to a psychiatric unit, because she couldn't figure out how to get that balance. That's something we all struggle with. Borgen, good show. Next slide. But I think if we look at things, how we can do it, how can we do that balance is just undivided attention at each stage of the things we're doing. For our patients, look at the patient and touch the patient. You know, people don't like it when you come in with your laptop, and you sit there your type away, and you don't even look at them, you just you just uh-huh, and you're typing away. They hate that. And if you're able to, hire a scribe, because that takes away some of the stuff that you have to do on the computer. And you can spend your time talking to the patient. Now, I know Don Shelborn is a great knee surgeon in Indiana, and he has people that have come to him for second opinions after they failed their ACLs. And he did a study and found out that these people had been done by orthopedic surgeons, but they had never been examined by the other surgeon. They looked at the MRI, did their surgery, and they failed. Don't be one of those. And if you can get somebody else to help you, you use some of your money to hire scribe. Next slide. And undivided attention when we get home. Now, our wife says, I only have two faults. I don't listen and something else. So I know, I'm a, I like to multitask. I like to watch TV. I like to read. I'm like, I'm on my phone. I'm doing things. I get them. But when I get home, my wife has had a busy day and I need to spend time talking to her, not doing five other things at once. So that's something we all can do. We get home, pay attention to your significant other. It really will pay off and listen. Next slide. But uninvited attention to yourself. If we don't take care of ourselves, we can't take care of others. So I've, I've done a study on trying to look on anti-aging. I really need to know about anti-aging right now. Right. And you know, the Mediterranean diet is really important. You know, if you can do something like that in 30 minutes of high intensity interval training, you can take 30 minutes to go out and do some sprinting and running or be on the Peloton or something, but take a gratitude walk. It's something my wife and I do. We thankful all the things that we have naps. I think right. Boost your growth hormone naps are one of the best things you can do. And now we know yoga, meditation hobbies. I have a guitar back there. It really has helped me. But one thing that really has been good in my life, audio books on my car. I love reading, but I was too busy, but I had two hospitals. One were 30 minutes away. I tell you that 30 minute drive to ER at a 3am. If you have a Lee child or a Diana Gabaldon book or something with some sort of fun book in there, it can help you stay awake on the way up and more importantly, on the way back. Next slide. Now, what about the pandemic? You know, I think it's really intensifying feelings of depression. You know, I have an easy life. You know, I work in an office. It's very safe. My surgery is in a surgery center. It's very safe. And I decided I better find out what's really like, and I talked to one of my daughter's friends whose husband is an ICU doctor and listen to him for, he gave me an hour of his time, how hard it is for him. He's in a COVID unit in Charlotte. You know, the 12 hours, the mask is a migraine headache every day. He's petrified that it's going to bring that disease from the patient home to his wife and his two children. And he's just said, it's horrible. And I said, how are you going to, how are you getting through it? He says, well, I exercise, you know, but we're all of us are depressed. And I said, you know, you're doing so much more than I am. What can I tell the people in this webinar that can help them? And he said to me, it's okay to be not okay. We're all struggling and it's not something you have to be like the superstar and you can't feel bad because things are bad. We're all having trouble. It was so valuable to me to hear from him. Next slide. And when to get help. You know, if you, some of these warning signs of suicide, you know, you start looking for a way to kill yourself. You're feeling hopeless. You're feeling trapped. You feel like you're a burden to others. You know, you start using alcohol and drugs too much. You're acting agitated. You start isolated and you start going like crazy rage or saying, I'm going to get revenge over something and mood swings. So if you have yourself, have this or a friend start talking to them. Next slide. How to help others, you know, be there for them. Listen, you just to say, look, let's go out and have a cup of coffee or sit and just talk to listen what they have to say, but encourage them to get help. It's not a, it's not a terrible thing to get help when you need it. And even a text can be lifesaving. If somebody's really struggling, just be there for somebody. Next slide. Here's a suicide prevention line. It's the general one. And so, you know, in, in Maryland right now, we have 3,500 people a day calling a suicide prevention line. It's like a major problem. You know, Annapolis, we have one person a day jump off the Bay bridge one a day. It's crazy. But I think the hospitals have to help us too. We're not superheroes. You know, we have, we have our own set of problems. We have to sleep. We have to eat. We need to decompress. And one of the things that can help us is, you know artificial intelligence. I used to be afraid of it, but I've read Eric Topol's book on deep medicine and it can help us like not doing so much administrative work. One thing I too, I think it's really important for us that are educators is that we want to educate our, our residents or fellows or students and not humiliate them. You know, M and M should be a time when you learn, but not to like rip the person to shreds. And one of the things that's really important is mentoring. You know, if you have a good mentor, it can help so much when there's a problem and for you to be a mentor to the younger people, you know, be there for them. And, you know, it's so important for us to realize that all of us are struggling. We all need some help, but we can all help each other. And that's it for me. Thanks. Thank you, Dr. McDevitt. That was tremendous. I wonder why you think that so many physicians, when we're trained to help people and obviously, you know, Hippocratic Oath do no harm first, do no harm. Why do you think so many of us have such a hard time talking about this? Well, I think like, like you said about being resilient and being, and being having tough grit, you know, we're supposed to be those superheroes. Those great people don't have problems. You know, we're supposed to help other people that have problems, not the ones that actually need it. So it's a sign of weakness. Plus, I think a lot of people are worried that if they say, I'm taking some psychiatric medications, or I'm seeing a psychiatrist, it may, it may hurt them in their practice. And maybe the hospital says, I don't think I want you to have that. Or maybe in a malpractice case, they're going to bring it up that this doctor was taking an antidepressant. So there's a lot of stigma about doctors having any kind of medical problems or mental problems, for sure. And that stigma has got to stop. Yeah, it's interesting, because I had been reading that neurosurgeons have the highest rate of depression, Dr. Swisher may know differently. And that that is, is a cause that you were saying, the concern about your medical license or privileges, because states do ask if you've been under care, some of the states I think have changed, you know, to ask if it's if it's under psychiatric care or medication that would impact your practice. But I do know that that does lead a lot of people not to seek help, even just psychological support or support from friends. What do you think we need to do in the orthopedic community to help each other? Because we certainly see it, especially in sports medicine, trauma, et cetera. What else do you think we do besides reaching out individually? Well, I think like even at the MNM conference, we can talk about things that are how you're feeling about what happened. Instead of like yelling at somebody and telling how stupid they are, you say, well, they could talk about things that happened in their life to staff people and say, I struggle with this too. A lot of us have PTSD, the stuff we see in orthopedics is brutal sometimes and we need to talk about it. At our hospital in Annapolis, we have a called a diastolic hour where we come together and we have like poetry reading or learn a little bit about medical history, some interesting things. But then basically we sit and talk about things that are bothering us. And orthopedics, we're supposed to be the big tough people, but we're like anybody else. We struggle with a lot of things just like all specialties do. We just got a question about this problem about paying out of pocket rather than having insurance pay for it and concerns about your practice. Do either you or Dr. Swisher know if that can be a problem for hospital privileges? Yeah, I don't think so. I think the only time it does become an issue if it impacts your work, meaning if your psychologist or psychiatrist says that you have to change your schedule or if you need to be admitted for severe depression, that sort of thing, that that degree of depression may affect your practice. Dr. Swisher, do you have something to add, please? This is a individual state issue and it's changing over the last two years. It's something that I've worked on with AMWA. We are doing an initiative, Humans Before Heroes, and looking at the medical licensure at each state. And it's different. And it's different from the published literature. More than half the states now have American with Disability Act compliance. So you're right. The problem is with impairment, not illness. So you can have an illness. It can be anxiety, depression, diabetes, asthma, whatever. But as long as it's not impairing you to do your work as a physician, most majority of states now have language that you don't have to report that. So say you're having stress over a malpractice case or a divorce, something going on with your family. Your child is having issues. You're going to family counseling. As long as it's not impairing you as a physician, for many states, you don't have to report. In Pennsylvania, there is not a question on mental health. There is some in substance abuse. And right now there's a New York physician who killed herself in April after contracting COVID. She was treating patients. Wannabreen was her name. And there's an act trying to move through Congress to protect healthcare workers on this issue. The sad thing was she was in New York and that's not a reporting state. So would it be fair to say that since we're thinking of this as a human condition, that we could think of it as like a physician who has a seizure disorder or severe, let's say diabetes with a pump, that if there is not an impairment of that condition, then you're good to go unless you yourself, let's say you're a surgeon, you have seizures, you're on a new medication, maybe you want somebody else in the room. Like if you're in a rough state of mind, for example, you might ask for a colleague to be your assistant on the case or something, but you don't have to take, like in the olden days where you would have to get, like I know some states required a letter from a psychiatrist to say that, yes, this is a patient and the patient is not suffering the doctor from any impairment. Is that a fair statement to look at it that way? Yes, in the summer of 2018, the Federation of State Medical Boards put out several recommendations on how individual states should look at their licensure questions. And they are looking at trying to bring mental health, physical health together and not separated. Okay, all right. Well, I think this is a really good time to transition to Dr. Swisher's talk, and we will definitely have time to visit more questions and discussion. So go ahead. Can you see my slides? Yes. Okay. I'm not sure why this is... There we go. Okay. So hello, I'm so glad to be here tonight to talk with the orthopedic community. My name is Lois Swisher, and I am a co-founder of the National Physician Suicide Awareness Day. This started out of emergency medicine in 2018. And it really sprung from an event in 2016 where a resident at the University of Kentucky killed himself over a sick family member. And a few of us were touched personally in different ways. Although I did not know this resident, his program director wrote a letter three days after he died, saying that we should shine a light on mental health saying that we should shine a light on this, speak its name and create a legacy. And that's how I really started becoming an advocate and telling my personal story. And I do also happen to be a clinical professor in emergency medicine at Drexel with the Drexel Connection. So I was glad to hear that. And I do have my contact there, lswisheratmercyhealth.org. If anybody feels personally connected with this, certainly you can feel free to reach out to me. So I have no financial disclosures, but I do like Dr. McDevitt, I do have a disclosure that this is a very personal story that I'm going to share. And if this is something that makes you uncomfortable, I will be talking about suicide in a detailed way. Please feel free to leave, take a break. I don't wanna trigger anybody, but I want you to know that this, but I want you to know that this, I am aware that this is very personal. So the way I think of this part is it's where the rubber hits the road. It's where we talk about what actually happens. We talk a lot about the theory, but what happens when it really, you wonder, you wonder, is there that person at risk? What should I say? What should I do? So I'm going to alter my story just a little bit, but enough to ring true in the orthopedic community perhaps. You have a call to the ER, there's a patient with a dislocation, they want you to come see the patient, and you're walking down the hallway. And you realize that the person on, you hadn't seen in a couple of months. You heard that her daughter had been at Children's Hospital of Philadelphia, child had a brain tumor, it was cancer, had been out of work for about two months, has been back for a few weeks. You wondered what you were going to say. Well, to tell you from the other side, that child who went to CHOP did have a brain tumor. And while in the MRI suite, the neuroradiologist came in and says, yes, mom, it's a brain tumor. As she ran out of the MRI room and turned around, could see the big screen. And this is what was on the big screen. And with that, all the feelings, all the feelings of a doctor looking at that big white thing in the middle in the child's brain, thought of all the possible complications. And how could it possibly be that big? And then all the things as a mother, when December 3rd, before Christmas, what was going to happen, those feelings converged. And then child went to the ICU, had the brain tumor removed on December 5th and came, left the room yelling, it's my brain tumor and I want to keep it. Came back mute, paralyzed, incontinent, unable to see, unable to swallow. And we started all over again. But because she already had the surgery and this happened to be a medulloblastoma, she was going to need radiation. And they told me, the mom, the complications in a five-year-old child, that boils down to, we're going to make your child sick, stupid and short. And then please sign the consent form. And then please sign the consent because otherwise she could die. So we did the radiation and we started the chemotherapy. And on the last day of radiation, I knew the next day would be my first day back at work. So now, you know the other side of the story. As you're walking through the doors into the emergency department, you see me. Maybe you don't know much of the story, but you know a little bit. You know that five-year-old child was at CHOP for two months with a brain tumor. It's cancer. And what do you say? How are you? How's your daughter? Couldn't be anything, but I'll tell you what my response was. Well, I'll tell you my beginning response and then as it went along. I now work at Mercy with Trinity. At that time, it was Mercy Philadelphia Hospital. So I work in a Catholic hospital. And when I first started talking to people, my response was, if there was a merciful God, I would not be here today. But I guess there's not. And it was met with silence. And we moved on and we talked about the x-rays and we talked about the patients and that was it. But it didn't stop me. Didn't stop those thoughts. And I moved down to the thing that I ultimately decided was what I wanted to do. And that was when people asked me, how are you? I would say there's nothing going on today that a hundred units of insulin wouldn't cure. Now I'll tell you there's psychiatrists and there's hotlines and there's people that are experts, but the person that's going to make the most difference is the one that's arms length away. The one that that person is reaching out to. And the thing that taking a few minutes of when you hear that, you may hear I'm thinking of killing myself. I could take a bottle of Tylenol today. Some jokes about propofol. And the decision, is this something that's black humor? Is this real? And I would look at those eyes and I knew that they didn't know what to say. They were worried. Do I have to take my colleague to crisis? If I say something, will I be legally responsible for what I say? It is not a doctor patient relationship. I've talked to lawyers. You're going to be okay. It's not a malpractice thing. You'll feel awful if your friend kills themselves, but reaching out to somebody else does not put you at risk. And the important thing is when you reach out and somebody starts to talk about it, it takes the power away. But nobody did that for me. Nobody asked. And this is where I ended up. This is at Mercy Philadelphia Hospital at the sink in the med room before Pyxis. I was able to get the insulin. I was able to get the needles and I rehearsed what I would do if it came to that point that the torture was so much that I couldn't take it anymore. And on the day that I was standing there with the syringe and the bottle, which I found was hard and cold. And I thought that was pretty appropriate for the situation that I thought, is there anybody I could reach out to? And I did reach out to that person and it made a difference. And obviously I'm here today. So it didn't have to be as torturous as it was for me. And I want to talk about that because as people that have been on the suicidal journey, it seems pretty scary to others. So for me, there's nothing going on that a hundred units of insulin wouldn't cure. That was my reaching out. We don't teach people how to reach in. Not yet, not in medicine. But I will tell you that the veterinarians have started this year. This is one of the programs. Ben Banfield put money behind this because veterinarians, their numbers are actually worse than ours. One in six veterinarians consider suicide. Male veterinarians are 2.1 times as likely to die from suicide than general population. And females are 3.5. And they put together their own program that you can look at on the computer called ASK. Assess, support, and know. Now, before the veterinarians did this, the construction workers, they've been doing this for years. And if you look at construction workers in suicide, they have a whole program because construction workers is the number one occupation related to suicide. And it makes sense. It's seasonal. People get hurt. They may take opioids for their pain. It's a macho field and may get in trouble with alcohol. Construction is actually an area that has looked at this a lot. So let me use the veterinarians. Assess, support, and know. So when somebody says 100 units of insulin, how do you know whether they're in a problem? Well, the first thing I want to tell you, and as I started telling earlier, the suicide journey, you don't really go from low mood to crisis usually immediately. For me, it was that low mood, looking at that MRI, and then thinking about death, the merciful God, getting active ideas, and then practice. It can take a while. So when you hear somebody's in trouble, don't assume that they're right at the ledge. They just may need an ear to listen to them. When I actually started working on this, 16 years after that, somebody asked me to do a wellness wheel. And which of those areas were impacted? Now, this wellness wheel is eight areas. And I was able to put in little different black shapes to indicate where the amount of impact. And when I was done, I looked at it and I'm like, man, it looks like shrapnel just blew up my life. And it really did. But the thing we decided in emergency medicine is like, this should be like anaphylaxis. If there's one area, one organ system that has an allergy, okay. But when you get to, that's when you pull out the EpiPen. When you know that there's two areas in a person's life that is having a problem, regardless of what you think, that is the time to say, hey, I know that these can be tough. I've been there. I'm a person to talk to. And I think as doctors thinking of this like anaphylaxis, two systems, ask, that's the time. Then it's what are you gonna say? And honestly, it doesn't really matter what you say. The thing is, is being there, looking like you're connected with the person, but there is a theory. It's called the three-step theory. And to know when you're in trouble. The first question to ask, are you in pain and hopeless? The second one, does your pain exceed your connectedness? And the third one, let me tell you, we all have. Do you have the capacity to attempt suicide? In medicine, we have the knowledge, we have prescription power. You don't even really have to ask that. And maybe one of the reasons physicians are at risk is we already have one strike against us. So what's the next part of ask? Is the support. That listening is really, really critical. There was a person who was going to jump off the Golden Gate Bridge, Kevin Bathia, and a California Highway Patrol person who was, it was his job to talk people off the bridge, went. And for an hour and a half, he listened to this guy who was standing over the edge. And ultimately he came back over. And the California Highway Patrol person said, after listening probably 87 minutes of that and the other three minutes talking, said, what made you give life a second chance? And he said, because you listened. It can be that easy. You're like, oh my, but I have so many things to do. Just saying, you know, I think you need to talk. Here's my number. Can we talk later? Is there somebody else you can talk to? You don't have to do everything at that moment. You can check with the person and see how much on the edge they think they are. Okay, and the last thing I wanna give you is some resources and the knowledge of what to do. There's a theory called Joiner's theory of suicide. And when you talk about all the things you can do for wellness, that's great. People go on towards the top, I'm all for it. What I worry about is those people that are falling out the bottom and it boils down to these three things. The bottom on capability for suicide, physicians, we all have that. So the two things that we have to look at are the thwarted belongingness and perceived burdensomeness. I change it, I'm an ER doc, I want it to be easy. Thwarted belongingness is isolation. You feel like you're being kicked off the island and perceived burdensomeness that you're imposter, you're not good enough. You're just not living up to the expectations. You don't have a purpose anymore. And if we focus on those two things, the connection and purpose, they make a difference. So what are your resources? There's the Employee Assistance Program. I suspect most employed physicians have access to this. And at my place, I can get six free sessions. They're confidential, they don't go on my record. And I've been through Employee Assistance Program twice. The last time was in February when Mercy Philadelphia was being sold. Just found that out. My father had a large bleed injury and father had a large bleed in his head and was disabled. And the pandemic was coming to kill ER doctors. I felt I needed some help. There's the Suicide Prevention Line. Yes, they will talk with you. And there's a text line for those millennials that feel much better texting. Early, we talked about the Physician Support Line. The founder of this is very much concerned about confidentiality. And this is a very confidential line. It's something that you can use. It's between 8 a.m. and 3 a.m. And they will talk with people. It's supposed to be in the crisis. If it's an ongoing thing, they will help find resources for you. Who I wanna leave you with, this is my daughter. It's been 21 years on December 5th that she had her diagnosis. And I say, if I would have known that life would be like this now, I wouldn't have been like that then. Don't assume that you know the future. So do you need to be knowledgeable about suicide to make a difference? There's a guy, he's passed away, but his name was Donald Ritchie. And he lived across the street from one of the most famous spots in Australia to kill yourself. And that was called The Gap. And he lived there for 50 years. And he would look out his window, sometimes with binoculars, sometimes walking down, and he would see a person linger. And he would walk over and say, hey, can I help you? Would you like to come for some tea? What's going on? And he's credited for saving at least 160 people. And all he did was invite them for tea. So invite people to talk with you, invite them for tea, and they'll make a difference. Thanks. Thank you, Dr. Swisher. I think we all need a moment to let that settle in. You really went over a lot of important points. And for multiple reasons, I just can't thank you enough for telling your story because on some level, telling it, you go over it again and again. So some of those rough times and feelings really have to come back. But seeing pictures of your daughter and hearing how well she's doing, I'm certain help combat all that and helping everybody else is really wonderful that you're able to do that. I have a preview for you for next week. I saw what your next week's topic is. It's second victim. Yes. And there's six stages to second victim. And I think that this is true with this type of thing. There is one stage that is the most important, and that's the fourth stage. It makes all the difference. It's the stage that we're afraid of. It's why we don't talk. And that's called surviving the inquisition. Part of it is we learn in M&M and things like that, how painful and difficult that would be. And so we fill that gap between when you say something and when somebody else says something with the most horrible things. And if you can survive that inquisition, whatever the questions are, then you can heal, you can survive, you can thrive. And now this doesn't hurt me tonight. People worry about me. I now worry about other people because that story, it's part of my history. It happened. Thoughts don't equal actions. I did have a counselor at that time. I did talk to him. This was a marriage counselor. And he said, I told him this, he knew this. And he said, well, you're smart. I would think you would think of every option. And I did. I don't think that that was quite the right way, but thinking about something doesn't mean that you're a bad person. Think about suicide, doesn't make you weak. It makes you somebody who thinks of all possibilities. And I'm an ER doctor. Why wouldn't I think of all of them? It's the way I'm built. Right, yeah. Well, it's terrific that you're able to overcome it because a lot of, some people can't and it's painful for them for forever, it seems. But one of the things that I've noticed too is that this idea of people think that they're not getting into trouble because all they think of is, I don't wanna wake up tomorrow. Maybe if I just disappeared or like in the ED, you and we as orthopods, we'll see people that used to be careful drivers, but now they're a little more reckless, that they're not as careful as they used to be. And so I think we have to be aware of that also with our friends, if the careful driving becomes reckless driving, if the one drink a night becomes several more, or like in your case where that seemed pretty darn blatant, I would hope that if a friend of mine or colleagues said that, that I would invite you over for tea. I have asked people to call me before they consider doing anything. Does that sort of buddy system help? I definitely think so because it's hard to know what the first words are. On either side. So I have a friend, his daughter had just finished her chemotherapy when my daughter started. And we talked about being overloaded in your life. He was the chief financial officer of a resort in the Dominican Republic, and he knew the cruise ships very well. He told me the line, you know what that line is on the cruise ships where the top part's white and the bottom part's like red or blue usually? He goes, you know what that is? Is that's called the plimsoll line. And the plimsoll line is when you look at that ship, you can tell whether there's too much cargo on it. Because if you can't see that line, it's too far down in the water. It's not safe for open seas. It could capsize and it shouldn't be sailing. Wouldn't it be great if we knew that whether people were above their plimsoll line, but we don't. So when I was having particular struggles, and I would call him, my first words were, I'm above my plimsoll line. And so like, get ready. And as soon as you heard that, it's like, okay, well now we know what we're gonna do for the next half an hour. You didn't have to be as blatant and they got the person ready. I think having somebody to talk with is really important. You know, I wanna thank Dr. Swisher especially because all my family says, dad, this is kind of a depressing topic, but I thank you because you gave us a happy ending tonight. And I think the happy ending, not only is your own success and the wonderful success of your daughter, but the Mr. Richie story, where there's a man that went out of his way and saved all those lives. So all of us can be like a Mr. Richie, for our colleagues that are struggling. So thank you very much. Well, thank you. I love that story. There's some great clips out there. Thank you. So Dr. Swisher, we have some resources on our webpage, but we didn't, I mean, they're on your slide, of course, the Ask program. If people were interested in more information about that, could they just like, you know, Google the Suicide Ask, to get some more information on that? I can tell you the American Association of Suicidology was involved with that. I would probably go with Banfield Veterinarian and Suicide. It will come up if you Google that. The American Association of Suicidology, which I am a member. Who knew that there was a society that studied suicide? And they're older than emergency medicine. I joined them. And if you contact them, I'm sure that they would be able to get you a contact if you can't find it on Google. Okay, great. There's another program essentially just like that. It's called QPR, Question, Persuade and Refer. And that has up to a six hour specific for physician program to teach how to ask, because Washington State requires physicians to have six hours of training. That's why it exists as a six hour. You can do it as an hour thing too. Okay, that's great. Yeah, because some of the references that are on our resources were things that were developed for veterans, because that's a VA and it's our tax dollars at work, but it's a good general training. But what you just mentioned sounds absolutely tremendous. And I thank you for looking ahead at our second victim syndrome. That also came out of another webinar. Dr. Morali is gonna lead that. And I just wanted to mention that our current president is Dr. Dawn Laporte for RJOS. And we're all very happy at RJOS and AOFAS that someone like yourself from emergency medicine has been able to be here tonight. And we do have one other question about insurance, meaning we were talking about the concerns about licensure and getting help. One of the things is like, will it increase your malpractice insurance? And is that a discoverable condition? For example, you have a malpractice case, is the other side or their attorney or whomever able to get this information about the surgeon? I don't have, what? I don't think they can. I think it's not discoverable. I mean, they can ask you a question in deposition, are you taking antipsychotic medicine, I guess, but you don't have to answer. But I'm not a lawyer, so maybe we could get that lawyer help to find the real answer. Yeah, and I think state by state how that goes, I would defer to a lawyer on that. I know that I am very open and I am discoverable on all of this. I mean, this is reported, this is going to be available. The thing that- Do you think perhaps people that are concerned about this issue, they could just check with their state medical board and maybe talk to the physician in charge just to find out or send an email or should they check with the hospital attorney or where's the best place to- I don't think any physician is going to call to anybody that they know. Good point. The program director that was so upset about his resident killing himself, I was like, you just don't understand, Chris. I would use every ounce of my energy to pass for you and you're not even my program director. You just have the perception of so much power, even if that person wants to help. I've recently started talking to the president of the Federation of State PHPs. Every state is different. And I personally am somewhat nervous about this, but they've assured me that you can make calls and make inquiries about these types of things and how it has worked. Right now, there's some review from the Federation of State Medical Boards about impairment and how that's the draft document on that and how it's going to be looked at. So there might be some changes coming in. I understand the concern. Some people will have stories that don't go well. I can tell you for me, it has been the most healing thing and I'm a much safer doctor, practicing physician because I have gotten those things healed. Another success, you know, because you got it all together, so to speak, but it's quite a journey, quite a journey. Yeah. I've said, silence is the prison and I thought that was keeping me free. It was not true at all. Another thing I learned tonight, we got to be very nice to our veterinarians. You know, those numbers of the veterinarians was shocking. One of my high school classmates, her father is a veterinarian and committed suicide. Yeah, as I recall, that was the first personal, I think then that brings up another point. I think if we all think about our lives and the people that we have known or friends of friends or distant family members and the people that we've met, friends of friends or distant family members, we're all gonna have a story. You know, we're all gonna know someone who has committed suicide and so, or has, sorry, died by suicide, which reminds me, that is a point that we needed to make that the correct discussion phrasing is died by suicide. And that's why we have the title tonight, Commit to Act, to make a plan for yourself and invite a person to tea or whatever, how that means to you. If you're a coffee drinker, this is making my mother happy in heaven to hear that this is another great example, take people to tea. What's your people at the top? People at the top are carrying a lot of burden in medicine, making decisions. My CMO and my CEO are not quite as taken aback when I randomly tell them not to kill themselves because I don't ever expect them to tell me if they're in trouble. But I know that there has to be heavy burden right now on the people making decisions. Yeah. Well, let me see. I don't see any more Q&A from our audience who I greatly thank for attending tonight. Feel free to contact me through RJOS or my Google voice, which is 856-362-4137. It takes an email of your call or if you need any resources to contact any of us. And we all hope that you have a wonderful holiday and we look forward to seeing you on our next series of webinars. Thank you, everyone. Thank you.

Physician Wellness Series

Physician Suicide

Ruth Jackson Orthopedic Society

Dr. Marlene DeMaio

Dr. Edward McDivitt

Dr. Lois Swishner

Orthopedic Foot and Ankle Foundation

Medical Organizations

CME credits

Mental Health in Medical Community