i am josh rushing filling in for fit me ok and you are in the stream today do no harm is the main tenet of the hippocratic oath but what happens when doctors have to navigate a system that can prevent them from putting patients 1st today will explore what some are calling a public health emergency in the u.s. doctors who are so burned out that their quitting or worse killing themselves in shocking numbers why is the system letting doctors and patients down are you a medical professional we want to hear from you join the conversation in our live you tube chat to doctors have already said a sort thoughts here take

a look. doctors have the highest suicide rate of any profession i run a dr suicide hotline and i've investigated more than $1300.00 doctor suicides root cause analysis reveals human rights violations as the culprit doctors who don't succumb to suicide are victims to coping with abuse is not a solution ending abuse is injured morals offers no solution burnout is just a smokescreen human rights violations are killing doctors and patients let's focus on facts and real solutions so when the insurance company calls and says that they're not going to pay for the medication that you perceive writing or when a hospital administrator said you must discharge your patient today obviously these are examples that your ability to provide good patient care but they also come to

you as if you've made the wrong decision and that can be felt as an attack. so get this every year more than $1000000.00 americans lose their doctor to suicide now traditionally in the us doctors have been viewed as noble well paid i mean really the peak of success so what happened why are so many doctors so deeply unhappy a 2800 opinion piece on this topic received a surprising response in it 2 doctors argued that medical professionals were experiencing a kind of damage to their moral code they know how to best care for their patients but are blocked by systemic barriers related to the business side of health care leaving them to ask what comes 1st patients or profits we're joined by one of the authors of that piece dr wendy deane she's a psychiatrist by training and co-founder of moral injury of health care dr joe winner is the position and founder of meditation in medicine and dr gabe her bondo

is a family physician and creator of bite burned out all right thanks for joining me on the program windy 1st on do someone go ahead i'm going to tweet out your article for our audience don't read it now watch the show but you guys can check that out right after the show wendy doctors have the highest suicide rate of any profession in the u.s. what's going on. so i think that physicians are are trying they've come into this profession as a calling and they knew that it was pretty hard when they got into it they knew it was going to be long hours they knew that they were going to sacrifice a lot in their adult lives and then what happens is when they leave medical school they take an oath to put their patients 1st as a priority and as they get out into practice they realize that they can't just take their patients 1st as a as a priority sometimes they have to consider what the insurance company needs what the electronic medical record needs what their hospital or health care system needs

and every time they have to choose other than their patient as a priority they sustain a moral distress and when those a mass day after day week after week month after month and year after year they amassed into a moral injury and it causes physicians to really wonder. what how can i maintain my own moral compass and continue to work in a system that asks me to do these things that don't put my patient at the top of my mind whether what was the response to your piece came out but a year ago a little over a year ago right it did it came out in july of 28000 and really it had been for us and explore thought experiment we had. talked to our friends who thought who had told us that they were very unhappy but that burnout didn't really fit what they were experiencing and so we put this idea of moral injury and health care out as a thought experiment and really didn't anticipate that the avalanche of response

that we would get to it so the regional article has had 275000 downloads it was the 3rd most read article. last year even though it was published in 2018 and so we and we've gotten hundreds of e-mails and i've gotten multiple phone calls and the typical response from people is thank you for giving me the language that i've been looking for for the last decade or 2 to really name what my experience has been and speaking of the linguists gabe i want to go to you what do you think about using this framing moral injury for what doctors in the us are experiencing. you know i pursued a question that i really want to start by thinking that you know when the and i are on the inside of this issue you have doctors and patients that are suffering and so the language whatever you. put it to a better place and you know i really believe there is a place for both burnout and injury and so i do sometimes get frustrated when they

are not or not or not at all injury the reason for that it turned out the research for a very long time after intervention validated will be our going but it doesn't answer everything moral injury thing you offer and help people understand what i mean the umbrella so so so i think both need to that so that we can get a better life that we're looking for. joe and i just want to say for the audience here actually i asked everyone before the show they're all doctors they should be referred to his doctors they all gave you permission to use their 1st name for the ease of today's conversation but i want to take the conversation now to jill who sitting in atlanta georgia you're a physician dr did you experience a kind of burnout what did you go through and does moral injury ring true for your personal experience so i i had burned out several times throughout my career but

not was always the language that i knew so this is how i tell my story although i do definitely agree with a lot of the philosophy and and truth behind using the term moral injury for me in 2011 i got severe burn out and i was crying every day and one little thing would go wrong and i would just snap and have to leave my office and i remember looking next to my at my calling i was hospitalised which meant i took care of patients who were hospitalized in the patient in the hospital and so. i didn't have a private practice where people my patients would come and see me in a physical office and so i turned to my colleague and i said we hate this job this is horrible and he said no it's a great job we're fine and so for me that's when i knew there was something inside of me that wasn't responding well to my current work situation and then i've learned this meditation practice so i'm on the show today because i and 2015 left my clinical practice to teach meditation and other stress reduction modalities the

health care professionals let me meditation helped me so for me it was all internal but i do also relate to a lot of the the struggles of you know get your patients discharged from the hospital but don't have high readmission rates and get good patient satisfaction scores but also make sure that you're not over prescribing opiates or antibiotics and. you know don't use good decisions when ordering tests but also don't. i also try not to get sued so there are a lot of conflicting things that are put on us as doctors that people don't understand and i think there is this sense as you are saying gosh that that doctors had this highly esteemed profession. we're all human and we're not perfect and i don't think we deserve to be treated like gods at all but i also feel that. there is a lot of stuff that doctors have to go through on a day to day basis that people just don't realize i wonder if people feel like or

doctors feel like that they don't have the right to complain because of where there could there could see there's a steamed or i want to get paid by the education level i'm looking at are are you tube which is pretty hot right now this guy named. me. no wonder i go into the doctors and some of them seem so depressed you can feel it in their offices you know when the i was thinking you wrote another article where from the perspective of the patient and do you share a little bit about what or at least your husband was the patient sure a little bit about that experience and what it told you about what doctors are going through. right so in 2016 my husband had a he has a longstanding heart condition that he was born with and it had been rare very well managed for years and at the end of 2016 and into the beginning of 2017 he started to compensate and during the course of that illness which became a critical illness what we experienced was

a complete disengagement of the physicians who were taking care of him and it was very difficult for us to come to contact the physicians when he was very critical it was hard to get them to engage in the it and to feel the sense of urgency that we had about getting him transferred and a lot of it felt to me as an advocate for his care. to to make sure that he got the care that he needed without the engagement of the people that i felt should be his advocates who are the physicians and what i realized was these folks were they were they were tied in knots and they couldn't refer outside of their system i think without suffering some consequences of their own. and they knew that they weren't taking the best care of patients or that they that they weren't being effective and they were they just it was it was so

disheartening and frankly frightening. to watch them. disengage from us the sicker my husband got the more disengaged they became and you know that's fine for me because i'm a physician i understand how the how the health care system works. but we had such a near miss that i started worrying about what about my friends and neighbors who don't have that same ability to advocate from a position of being you know an insider or well educated and how health care works can you know what maybe gave talk to me how does the business side of this play into it. so so so this actually ties into a little bit of what i like about burnout as the term is that there is an antidote which if you look at the research in professional book film and dr math and there are these 6 different things that fall into that category of that that need to

happen and so one of them is you need a reasonable reasonable workload and the physician workload iraq. a chart a lot of people and a finger there good reason studies that come out that show that you spend enormous amounts of time doing documentation and administrative work in that you chart and that was something that hasn't always been around so there's there's more work to be done with the same amount of hours and so the real issue and so there are there are there are some other mother issues professional woman who still lack of control a lot of become employed and. and and i don't think we realize the transition from a lot of the private practice to claim it how much control we were giving up and that is a big factor in the burn out. or what leads to burnout it lost control. i think peter seeing which for me what you see the difference between burnout and

moral injury are. you know i did i actually am so new to moral injury that i would actually prefer that when these speak about moral injury. but i can happily tell you about burnout burnout. exhaustion emotional exhaustion the personalization and he was striving and probably wasn't as a full human being like whatever the doctor was burned out and lost sense of accomplishment so you're just not accomplishing your work what you think you should be or or what you really should. just look like you want to jump in there and i'm sure yeah i think i think one of the things that i feel like there is this either or like are you team burnout or are you team moral injury and i don't think you get a break from anyone on this show i went the i've read your article and i think it's amazing and and gave i've looked at your work as well but there's this sense of like because moral injury now exists now doctors can stay mad and blame something

else and say ok and it's not it's the system so then i can just like be mad and unhappy until the system gets specs and that's that's where i come in because i feel like no matter how bad the system is even if the system was perfect you're still taking care of sick patients you're still having to deliver bad news you still have to stay on top of the medical literature it's stressful and it's scary and we should promote a culture where we're able as physicians and other health care professionals to take care of ourselves in a way that let us show up for ourselves for patients. and then show up in a healthier way so we can come up with solutions to the health care system that are not out of. stress about in survival mode but that are out of a place where our brains are rested and we're able to make the decisions and solve problems and communicate better because people get so angry i've seen a lot of really angry videos online about about moral injury and it's making up words so it's it has a lot of merit but it's so angry that i feel like it's not it's for me it's

frustrating as i'm not sure it's helping with solutions and when we cannot through a comedy show you out of our you tube. is probably in a ww. dollar dalan jones so is moral injury is a military term doctors can expropriate the term internal pressure dealing. beings i'm not sure but doctors have a choice soldiers don't. what is that right so i think it's very much akin to what happened with the language around post-traumatic stress. disorder where it did originate in the military for good reason. and there was much debate about whether or not that same categorization could be applied to civilians but i think we've we've shown that even though it comes from very different. drivers or from different directions that p.t.s.d. is an appropriate diagnosis in the military it's also appropriate diagnosis in the civilian population who have suffered trauma and i think moral injury in the

military population certainly is a valid one but i think that there are some aspects of the health care system and the position that physicians are in that we can also agree will transgress deeply held moral beliefs and so getting back to jill's point that. i absolutely agree that meditation and doing all the self care that that keeps us strong enough to go back and change the system is critical that is our baseline and that's something that we should be doing it's necessary but i don't think it's sufficient for us to change the drivers of of moral injury and to gapes point. with the difference between burnout and moral injury there are a lot of things that can drive moral injury that will i mean that can drive burnout burnout is a cluster of symptoms and there are many things that can feed into that but i think

what we've heard since in the 18 months since we published our article is that moral injury is a big segment of that of the causes so you talk about causes and also i talk about solutions. joel doesn't want talk about meditation with you before you do that we have a couple of comments from some doctors in our community who are all those we work up to if not more than 80 hours a week sometimes for months on end without weekends off. patients are then faced with doctors who are exhausted who want to check every lab who wants a fault in every exam finding and listen to every patient problem but there often is not the time and space for that to occur leading to errors and thus cyclical worsening of moral injury we need more residents we need more time off between shifts to recover we need formal training on dealing with an evitable bad outcomes we need a lot of change to improve moral injury medicine however as far as solutions i have 3 ideas one making step one passed which will reduce the burden of step one medical

trainees early in their careers to making the primary clinical year passed which will shift the burden of performing performance and evaluations to the fore in final year medical school when students are much more familiar with clinical work and they know what they want to go into and last creasing avenue therapy and residency and specifically showing that these services are covered by training programs now it's worth noting both those comments came from either medical students or young doctors but i guess my question is how most sinister and then we can talk about meditation as a way to respond to it but do doctors begin their career burned out coming out of medical school the data i read or heard about is that they go into medical school

not burn out and then they come out of it already having experienced some sort of damage or trauma or whatever we call it i had my 1st burn out my 2nd year of med school so i was maybe ahead of the pack on that front. so i think that. there is a culture in medicine that we are not. there's the strong this expression that we say strong work you know like the harder you work the earlier you get there the later you stay the more intense you are the more you come in when you're set then you're like a strong president or a strong student and so there's this culture that's perpetuated that the more you give of yourself and don't allow yourself to breathe and to heal that that somehow makes you better and that is perpetuate i think and wendy and gave you you may may have also your own experience with this i think that's perpetuated throughout medical education and i don't know where it starts and where it ends but but i feel like we need to get to it at the very beginning to change the culture which will

you remind me of the character in somerset bombs novel razor's edge larry daryl he ends up going to india after a war because that's the war really morally interplay didn't have those words back then because war wanted and he ends up in india kind of searching for peace or some solution you do the same thing right what did you feel you tell meditation i did i found out a taishan in 2011 when i was still practicing medicine and it really for me it is not mindfulness that what i practice and what i teach is very different from your traditional workplace mindfulness hourlong guided visualization so so i took this meditation course in 2011 and i had a really profound benefits really quickly i lost my road rage i stopped crying every day and i i was quite successful in my academic and clinical career for several years after that that was when i went to india for a retreat a meditation retreat and i started having some really really even more powerful experiences because i was never spiritual or open to meditation that you had people

that know me now think it's or that knew me then think it's hilarious that i'm a meditation teacher now because i was i was the type of med student to go out and and over indulge in an alcohol and study and party that was not i was not a self care kind of medical student. so when i started to have these experiences and realize that even taipei anxious doctors like me could meditate successfully and enjoy it that made me think what would happen if i became a teacher and i always just assumed that i'd come back to medicine and teach part time and practice medicine part time so it was never like i'm leaving medicine because i can't handle it or because i hate it i just realized i had this tool that could help wonderful people get to the point where i had gotten you know are you one twitter i am what you put your twitter handle out there right now i think a lot of people might want to be picking up what you're laying down here at. the it's ok can i make a comment about about meditation because i have some thoughts to share yeah yeah

sure jill will tweet out your you know what are all tweeted out. so 1st of all i practice meditation regularly i took and then b.s. our class 2 years ago and it changed my life and i think it's a it's a tremendously valuable tool i also have concerns about what exactly the role of it is helping with the burnout for example of this gets back to like our. language that we use understand what's going on so so if the model is burnout then really the research shows that the antidote is professional to film it and we've got this thing going now where there are programs which i think are very good programs like the well i'm the program at stanford and we're talking about wellness like. earnest but wellness is not the true positive or no question element of burnout and so so i think that meditation is extraordinarily important gives me reserves i don't have without it but i'm afraid that i'm just not sure that it's all the burnout epidemic

i don't know where meditation fall into to answering the questions about professional film and what does that do to reduce my workload what does that do to my control what does that do to increase the sense of fairness that i have about work what does that do to get more rewards work those are a few of the. only got about. 90 seconds left and i want to give jill and she has responded that some curves here answer i think that's a great question gabe and i feel definitely i don't think meditation will fix all of that i think there systemic issues and professional fulfillment is a huge part of it. meditation i feel like is a high performance tool so it's not just about stress management and feeling good but it makes your brain function better it gets you out of stress overdrive it helps you with problem solving i have students who have better called better clinical judgment because of that improved compassion and better intuition so there are so many other tools that come to it it's a huge tool but it's not the only tool for burnout absolutely then and i just think

that having a bunch of people in the right so i think and i think that they have the medication piece is actually exactly what you said it is a high performance it's a high performance tool that will prepare you or leave you the best prepared to tackle the drivers of moral injury or burnout are you guys look i'm going to have to start wrap this up in the problem as i want to show this tweet on my computer where someone tweeted said single payer medicare for all they answer simple and the problem meditation is this and the vigil thing about it i wanted to get to talk more about the system what needs to happen in the system here but we're going to have to wrap it so doctors when the dean job winner gave her bano i want to thank you for being on the program but let's continue this conversation on twitter after the show and for everyone watching i'll see you next time.

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