Pamela Wible, MD on physician suicide and medicine’s culture of betrayal [PODCAST]

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“When the medical profession—a career you have pursued for years, a career you love and trust to do no harm does something to shatter the foundations of your sense of trust and worldview, the resulting trauma can be severe resulting in loss of sense of self and life-altering betrayal grief that mirrors the stages of acceptance of one’s own death (or the death of a piece of one’s soul when swept up in the betrayal cascade)—denial, anger, bargaining, depression, and acceptance. As a witness to immense betrayal within the medical profession, I’ve felt them all.”

Pamela Wible is a family physician and author of Physician Betrayal: How Our Heroes Become Villains.

She shares her story and discusses her KevinMD article, “Medicine’s culture of betrayal.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Pamela Wible. She is a family physician, and she’s the author of the book “Physician Betrayal: How Our Heroes Become Villains.” Pamela, welcome to the show.

Pamela Wible: Thank you so much for having me.

Kevin Pho: So we’ll get into your book and excerpt in a little bit, but first off, can you share your story and journey to where you are today?

Pamela Wible: So I’m a family physician, but my parents are physicians. They warned me not to pursue medicine, and their warnings, interestingly, were more economic predictions that have come to pass: loss of physician autonomy, assembly-line medicine, the whole shebang, quick, you know, seven-minute visits. But what I found interesting is that they never warned me about the emotional impact of the career. So it was all economic, not emotional. Never once did they talk about their own anxiety, depression, suicidal thoughts. And so I was left in a very isolated state, feeling like I was the oddball, the only one having mental health problems, and I came to realize we have a real physician suicide crisis that I sort of stumbled upon by personal experience.

Kevin Pho: Of course, you need no introduction in terms of being at the forefront of bringing awareness to physician mental health and physician suicide. Tell me how you first got interested in this issue, and when did you realize that it is such a big issue?

Pamela Wible: We had three physicians that died by suicide in my town, in Eugene, Oregon, in just over a year, and that was in 2012. I was suicidal in 2004, and at the time I thought I was literally the only suicidal physician that ever walked on this planet. I think some of this is repressed memories from my childhood, because now, when I put it together, I’m writing my memoir, I realize, oh yes, my mother is a suicidal psychiatrist. I think I hid that from myself, and a lot of us hide our own personal pain from ourselves because it’s just too much.

And so, to be completely honest, people ask me over and over again, “Well, why do you want a suicide helpline?” And I say, “Because I survived suicide as a physician, so I want to help my peers.” That’s a superficial answer. When I go into my memoir, well, I was an embryo inside of a suicidal psychiatrist. I feel like I’ve been running a suicide helpline since I was born, or conceived, you know, quite honestly. So I guess that would be the true answer.

Kevin Pho: So you mentioned you did run a suicide helpline for health care professionals. Please talk more about that.

Pamela Wible: Yeah, so that just is nothing that I actually decided to do. I just fell into it, and people were utilizing me as a suicide helpline. So since 2012, since I became pretty vocal after the deaths in my town, people have been wanting to tell me the suicide stories of their children in residency and medical school. Suicidal doctors are calling, and, you know, internationally, from Germany and Poland, medical students, especially during the pandemic, right? I started having a greater influx. And so it’s hard to stop doing something like this, because I do have a lot of passion for it, and people seemed to be thanking me for helping them stay alive and telling me that. You know, the most common first line in an email that I got for some time was, “I would have been one of your statistics, but you answered the phone. I read your article. I saw you on KevinMD. I saw your book.” You know, and so it kind of makes you want to keep going if that’s the response.

Kevin Pho: Now, when you talk to these suicidal health care professionals, in general, what are some of the root causes that bring them to the brink of suicide?

Pamela Wible: I think we have a lot of unacknowledged, occupationally induced mental health issues, including, you know, obvious trauma. If you’re a trauma surgeon, I mean, it’s built into the name of your specialty. You’re traumatized by watching people on the edge of life and death and telling parents their teenagers are dead. And, you know, so I think we have to realize that just, even on the best day as an OB/GYN, you could have a stillborn amid a happy birth and then a maternal death. And so, you know, there’s no specialty that’s not traumatized. And then to not be able to get mental health help because we’re worried about our career repercussions, and also we have internal dialogue in which we feel like we’re supposed to help others and not be in the position of requesting help. So I think we have a very strange culture of emotional and spiritual disconnection from ourselves in medicine, which causes these wounds.

Kevin Pho: You’ve been bringing awareness to physician suicide and physician mental health for years now, and of course we’ve been talking about clinician burnout, clinician mental health, on KevinMD for years now. Now, talking in 2021, have we moved the needle in the last five to 10 years, after all the advocacy work that you’ve done and all the KevinMD articles that you’ve written, all the speaking appearances that we’ve done? Have we moved the needle, and if so, how much has that needle moved?

Pamela Wible: Yeah, absolutely. At the beginning, I could not even get the local newspaper, TV, to report on the doctors’ suicides in my town, and now at least occasionally they’re hitting the headlines, and they’re actually saying “suicide” in the articles. And hospitals are reaching out to me in the aftermath of suicides and having me lead postvention, like, immediately, within 24-48 hours of a death in their hospital, so that physicians get the help they need. Because the real problem with the suicide is the secrecy. Secrecy is the genesis of more suicides when it’s not handled up front, because it leaves the other passively suicidal co-residents and hospital employees feeling like, “Wow, this guy died in isolation. We won’t even talk about it. I can’t talk about my pain.” And so it becomes like a visible way to end the pain when you can’t find any other outlet. And nobody really wants to die by suicide. They want to end their pain, and that happens when we connect with each other and actually speak honestly about our experiences.

Kevin Pho: So when you talk about the secrecy surrounding physician suicide, what exactly do you mean?

Pamela Wible: The unwillingness to say the word out loud. The way that we will often miscode death certificates as accidents, when we know the guy was in the middle of a divorce or a malpractice case and he just, you know, drove off a bridge. And we’re in a unique profession in which we can complete the death certificates on our peers, and so we can hide this, beyond, you know, veterinarians or, you know, social workers, construction workers. I mean, we are literally covering, out of our own denial, which I was in personally about the suicidal crisis within my nuclear family. OK, it’s easy to go into denial because it’s painful, but we’ve got to talk about it, you know?

And yes, we’ve moved the needle. I’m doing keynotes for surgeons who are, I mean, I just had, this last Sunday, a surgeon support group, free, that I do on Sundays. And to have these older male surgeons breaking down and crying with one another, I mean, that’s moving the needle. I’ve never seen that before, and it’s great. We need to cry. We need to release the pain. Like I said before, I feel like we all need to do sort of a personal emotional I&D on ourselves. Otherwise, we are literally walking around in emotional sepsis.

People ask me, like surgery interns, you know, “Why is there bullying in the OR? Why are these surgeons acting this way?” And it’s like, I sort of try to use surgical terms. Well, it’s just emotional exudate. They can’t help it. Like, hurt people hurt people. If you can’t contain an abscess that large, you’ve got to slice it open and let it out, at least in a journal in your home, you know, or talk to a friend, or go to a therapist, or call me. Talk to me for free, you know?

Kevin Pho: So when you talk to these health care professionals on your hotline, what have they tried in the past to help address some of the behavioral health issues and some of the depression, burnout, and anxiety that they’re facing? What have they done prior to calling you on the hotline?

Pamela Wible: Well, most of them have done nothing, you know, and that’s the problem. And then sometimes when I hear from people, they’re on the brink of disaster. I’ve heard from a physician, you know, in the ICU, you know, after a suicide attempt. So a lot of times, just like human beings, our patients, they wait until they have a heart attack to make their dietary change. They wait until they’ve got a major disaster looming. So I think most people just try to suck it up, pretend like it’s not happening, until it completely overtakes them.

And what I do feel is so cool is that sometimes people will write me these tomes of emails, and they’ll say at the end, “I feel so much better for sharing this for the first time in written form. Don’t even worry about calling me back. Just thank you for reading this.” You know, so that’s kind of cool, the fact that just writing it down in an email kind of allows you to feel like there’s somebody on the other end that you can trust, that’s not going to report you to a medical board and that sort of thing. And yeah, so it’s really heartening.

And it’s especially great to get people in the same specialty together, you know? That’s why I do these sort of specialty-specific, peer-to-peer support groups, because I’m not a surgeon. I don’t know what it’s like, you know? They do. And literally these people are replaying every accident or bad outcome they’ve ever had in a 30-year career, like an ongoing videotape in their mind. They can’t sleep at night, and they all have this. And, you know, I don’t think in outpatient primary care you get that as much as in surgery. It’s very interesting.

Kevin Pho: So when you’re bringing awareness to physician suicide, have you received any pushback? Share some of the challenges that you face and overcome in bringing more awareness to physician suicide.

Pamela Wible: Well, the pushback early on was from the spouses of the physicians in my town, and I never outed them by name. I just wrote an op-ed saying, you know, “Hey, this happened.” And I think they were just horrified, you know, because there’s never a convenient time to talk about suicide, because there will have been one yesterday or two days ago, and somebody’s going to be grieving, and they’re going to lash out at the first person they can. That’s usually me. I’m the messenger, and that’s OK. I don’t mind.

I think what’s shocked me is the amount of vitriol that’s come from some, maybe ego-bruised, I don’t know, people in the psychiatry field, mostly female psychiatrists, which is my history with my female psychiatrist mom. I’m just kind of in a pattern with sort of angry female psychiatrists. But it’s a small subset. And I mean, they’ve been told, like, “Stay in your lane. You know, this is our area.” It’s like, this is a free suicide helpline. Like, I happen to spend thousands of hours listening to physicians crying on the phone. Like, I don’t think this is specialty specific. I feel like we all need to help each other, and we shouldn’t be getting ego-bruised, you know, if somebody’s ahead of you on understanding the genesis of what might be causing this.

And what I found really interesting is, during this last Sunday’s suicide support for the surgeons, there’s one guy in there who literally was inpatient psych, you know, several weeks ago, and he’s not sure he can make it day by day. And I’ve hooked them up, and he keeps calling me and the others. And so, you know, he’s still alive. He’s a cool guy, head of a department, head of a residency, you know what I mean? Like, this guy is awesome. He’s never shared this information with anyone, but at the end of the call he said that, you know, spending the two hours with us was more helpful than any therapist he’s seen, anything they did in inpatient psych, you know, any help that he’s gotten yet. And I feel like that’s because this is targeted, physician-specific help. It’s not like blasting people with chemotherapy, you know, for all cancers. It’s like, you figure out what’s going on. This is a very specific subset of people with very specific psychology, and they need to be handled in a specific and a non-generic way. And that’s not what happens when you get thrown into inpatient psych, or treated, unfortunately, by many therapists. So yeah, I’ve had pushback, but I have thick skin. I can handle it, so I just keep moving.

Kevin Pho: What are some examples of some of the criticisms that you face?

Pamela Wible: Well, I mean, I’ve heard things like, you know, it’s really interesting. Before I did a keynote at the Psych Congress, I always know when I’m getting sort of lambasted, usually in private sites. They don’t do it to my face, or there’s never live conversations. You know how vitriolic it can get on social media. I’ll get these Facebook private messages, “How are you holding up? Are you OK?” And usually when I get those, I know I’m being skewered in a private group, and it’s often before I do a speaking event. And, you know, they’ve actually contacted the places where I have speaking events and tried to get me fired while I’m there. They’ve boycotted the events. They’re really, like, a very angry, small subset of mostly female psychiatrists.

So this person that leaked this to me, I was like, “Well, what are they saying?” He’s like, “I really think you should respond.” “How can I respond? They’re doing it in a private group.” He goes, “Well, you know.” I said, “You know what? It’s probably mostly female.” And he’s like, “Oh, yeah, I looked at it. 75 percent female.” And I was like, “Yeah,” because women can beat the crap out of each other, you know, viciously, verbally, in a way that men just can’t.

And so he’d send me, like, screenshots, and he sent me a whole spreadsheet of the things they were saying. And, you know, one of the things was like, “Well, I can’t believe that they’re calling what Dr. Wible does research. I mean, that’s like saying my two-year-old wandering around my house collecting bugs and leaves is doing research.” And I’m like, that is research for a two-year-old, you know? Like, that’s kind of what you do, you know?

And it’s so funny, they’ll say things like, “I can’t believe, you know, she’s making money off of human suffering.” And so I literally went up during my full disclosure slide and started reading all the vitriol that they left for me online and answering it on stage. Because I don’t have any, there’s no conflict of interest. I’m not hired by Merck. I don’t have anything to share on my full disclosure slide. So I fully disclose that there’s a subset of physicians who don’t like me, and I just started reading everything they had to say and answering it on stage, and people were laughing and rolling. I mean, I ended up doing stand-up comedy after this. So I have to thank these people for bringing it up, because I do think controversy and talking about these conflicted thoughts really helps us grow personally. And I think tragedy and comedy are connected, and a lot of times when I speak about suicide, I mean, I’m getting standing ovations. I never expected it, but people really have a need to hear the truth.

One of the things I thought was funny, what they said, is like, “She’s making money off of human suffering.” When I said that, I was like, “Oh, wow. Wait, don’t all doctors make money from human suffering? Raise your hand if you’ve never made any money from human suffering,” right? And I’m not charging any individual physician for helping them. Yes, I charge for keynotes, you know, but that’s like 10 years of amassed, you know, research on this that I’m sharing, and graphs and charts, and that took a lot of time, you know? But yeah, I’ve never charged an individual physician who’s suicidal in 10 years for help. But I just find it, you know, it’s fascinating, the response that I get from a small subset of people.

Kevin Pho: You’re also the author of a recent book, “Physician Betrayal: How Our Heroes Become Villains.” There’s an excerpt of that on KevinMD titled “Medicine’s culture of betrayal.” Tell us more about your book.

Pamela Wible: Yeah, I was in the middle of writing a memoir, and then I had sort of, I don’t usually get writer’s block, I had writer’s resistance, and actually a betrayal scene with my dad at age 13, mostly because he’s a workaholic physician and you never see him. And so I was trying to kind of piece that together. And at the same time, I have this little coaching group of doctors, and I was like, “Oh, why don’t we do a 30-day book challenge? Let’s see who can write a short ebook in 30 days.” Because I like physicians to start expressing themselves and sharing their personal stories. And about 10 of them took me up on it and ended up as authors at the end of the month, which is awesome. But I like to do it along with them, so I wanted to show them how easy it is to write a book in a month. So I did this, you know, 32-page ebook in a month, which was a very painful exercise, but it sort of helped unearth material that allowed me to continue in my memoir.

So what I have on KevinMD is just chapter four of the book. And I just feel like the core issue we’re all dealing with is a sense of betrayal in our profession, because we come in as these idealized, you know, young, you know, do-gooders, and then we’re faced with unethical scenes that we’re in and things that we witness in which we literally have to betray our own ethics to continue an attachment with this career.

And there’s a quote that I came up with on institutional, well, it’s a definition, which I feel like people can relate to right now during the pandemic. “Institutional betrayal trauma occurs when the trusted medical institution that teaches trainees how to be healers fails to protect them and can so deeply contradict what is expected that medical professionals will end up blocking their trauma in order to maintain attachment with the profession.” And I feel like we’re all in various states of institutional betrayal trauma, and the sooner we talk about it, the sooner we can recoup our profession and become the healers that we had intended to be. The profession is not going to right itself on its own, and this is kind of a deep soul search that we need to do individually and professionally, as a group.

And I just feel like maybe the essay that I wrote, or the chapter on KevinMD, it, you know, it probably, it might have lost some people. You know, it might go over some people’s heads, you know? But I do think the book is pretty good, but it’s a deep dive into your own psychology as a physician and a healer.

Kevin Pho: So give us an example story, or a case study, of how an institution would betray a physician.

Pamela Wible: Well, I think it starts in medical school. For me, it started in the first year of medical school, when they had us do dog labs. Thankfully, that’s not happening anymore, as of 2008, I believe. But literally, just to see on my schedule that I was going to go into this physiology lab and murder a dog that was somebody’s prior pet, for no other reason than to study the EKG flatlining and look for heartworms. I was like, “This is ridiculous. This is not anything that’s going to ever help me with the human patient, you know, and could be learned in a different way if we’re just trying to study EKGs.” And so, but the physiology instructor told me straight away that, “This isn’t an experiment. This is an experience, and there’s no alternative.” And you know what that is? It’s an experience, and methodical dehumanization, which is what happens to us in this profession, which is almost run like a cult, which is why it’s so hard to get away and so hard to retain yourself when you’re in it.

And it happens just slowly over time, like this betrayal grooming. And it starts with your own choice to act against your values, which is, like, you know, death of the soul by a million paper cuts, from day one. And then people find themselves in a state of detachment, loss of joy. I mean, this surgeon who is suicidal, he’s like, he gave his life to this profession, you know? He’s an esteemed head of a department, you know, and he feels like, “What was this all for?” He lost his whole life. He was not really joyful in the profession. He just did what he was supposed to do as a good guy.

And I think we have to stop and pause and really reevaluate. Am I in a career cul-de-sac? Do I have joy? Like, am I getting to live my life? Because we, as healers, should get to live our lives and enjoy ourselves and have real joy, personally and professionally. And if you’re not feeling that, don’t wait until you’re in the ICU after a suicide attempt to reach out. Like, start talking about it now. Pretty much, I bet all your peers feel the same way.

Kevin Pho: We’re talking to Pamela Wible. She’s a family physician, and she wrote the KevinMD article “Medicine’s culture of betrayal,” and she’s the author of the book “Physician Betrayal: How Our Heroes Become Villains.” Pamela, what’s next for you in terms of moving the needle when it comes to physician behavioral health and physician suicide? How are you going to continue to move that needle?

Pamela Wible: Well, I think finishing my memoir is going to be really helpful, because it’s been more helpful for me than any therapy I’ve had, and I’ve had, like, 20 years of therapy. I think when you really sit down and, in a sort of fearless way, go back to the worst scenes in your life and marinate in them enough to write dialogue, and then, with the mind of a healer, with the wisdom of somebody who understands the DSM, which you obviously didn’t have a grasp on at age nine, when you can apply your adult knowledge to scenes in your life that never made sense to you, you finally have enough understanding of why you are where you are in the world and how to use your gifts to heal yourself and others.

I think a lot of healers are very other-focused, like, “Let’s heal other people.” And what I’ve learned from training hundreds of doctors to run their own practices is really their ideal patient is themself. It’s a mini-me. Like, we’re out to heal ourselves by focusing on others. But if we pause for a minute and really, truly heal ourselves by being introspective, fearlessly, which is hard, to go back into your painful moments of betrayal in your childhood and beyond, you will have such a depth of understanding of who you are that you’ll be able to give from a place of true insight, wisdom, and resourcefulness, versus algorithms, cookbook medicine, and that’s failed us in psychiatry.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Pamela Wible: Similar to me, clinicians out there, you have entered medicine without informed consent. I am a real fan of informed consent. I feel like people need to understand what the impact is of any choice, of any medication, of any injection, of any career choice, right? And so, people, you know, once you, and I’m sorry, I just want to say I’m sorry that you, like myself, did not understand the emotional impact of this career. But now we’re at a time in human history when it’s OK to say “suicide” out loud. It’s OK to say that you have PTSD. As a trauma surgeon, it’s built into the name of your specialty. It shouldn’t be a shock.

And so please ask for help. I have 10 years of free, confidential resources, including so many KevinMD articles I could, you know, give to you if you just reach out for help. You know, you don’t have to, like, Google all night long searching for things. Just talk to idealmedicalcare.org, and I can hook you up with recordings, with peer-to-peer support, with articles, you know? So just don’t do this alone. I feel like we talk a lot about teamwork in medicine. You should not go into this profession with a lone-wolf attitude. You need a team. Every one of us needs a team of healers around us. I mean, you go to dental, you’ve got a team. With your dentist, you’ve got a hygienist, you’ve got a dentist. You need an emotional support team to make it through this profession with your heart and soul intact, and you deserve it. And it’s your birthright to be happy.

Kevin Pho: Pamela, thank you so much for sharing your time and insight, and thanks again for being on the show.

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