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Pediatric nephrologist Katherine Twombley opens up about her personal journey and her book, First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement. Join us as she sheds light on the important topic of physician mental health, drawing from her own experiences and the tragic loss of her father, Dr. James Michael Twombley. Through candid storytelling and valuable insights, Katherine discusses the often overlooked challenges and struggles that medical professionals face, emphasizing the need for open conversations and supportive communities within the medical field. From addressing stigma to providing practical tips for self-care and mental well-being, Katherine offers a powerful message of hope and empowerment for fellow physicians and health care professionals.

Katherine Twombley is a pediatric nephrologist.

She discusses her book, First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Katherine Twombley. She’s a pediatric nephrologist, and we’re going to talk about her book “First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement.” Katherine, welcome to the show.

Katherine Twombley: Thank you. Well, thank you for having me.

Kevin Pho: So we’ll talk about your book in a little bit. First off, briefly share your story and journey.

Katherine Twombley: I’m a second generation physician. My father was an ED physician in a very small rural town in Dillon, South Carolina. I’m a pediatric nephrologist and the chief of pediatric nephrology at the Medical University of South Carolina, and I specialize in taking care of kids with kidney transplants.

Kevin Pho: All right, so talk about some common cases, common scenarios that you would see. I don’t get a lot of pediatric nephrologists on the show, so take us through a typical day, if there is one.

Katherine Twombley: Oh, a typical day. I don’t know that there is a typical day. So I practice in two places. I’m either in the clinic taking care of kids, evaluating whether they need a transplant, or taking care of them after transplant, or I’m inpatient covering the entire nephrology service.

We take care of children receiving continuous renal replacement therapy, hemodialysis, peritoneal dialysis, plasmapheresis, hypertension, electrolyte disorders. We’re in all parts of the hospital, which is one of the reasons I love nephrology, because I’m in the NICU, I’m in the PICU, I’m in the ED, I’m on the med-surg floors. It’s just a wide variety of patients, and that’s one of the things that drew me to nephrology.

Kevin Pho: All right, so let’s talk about your book. It’s titled “First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement.” Now, before we talk about the book itself, talk about why you decided to write it. What are some of the events leading up to you writing the book?

Katherine Twombley: So for those of you who have not read the book, I’m going to spoil the key to it. In August of 2011, my father, who was an ED physician, died by suicide. And obviously we were devastated, and through the healing process of this, questions kept coming up in my mind. Is this going to happen to me? Why did this happen? I’m the only other physician in the family. What went wrong?

And I started writing down things, and started going, wow, if we had looked at this, maybe this would have changed. Or if I had considered this, maybe this would have changed. And before I knew it, I kind of had an outline of a book, and that’s where it started.

And I feel like physician suicide is talked about now since COVID, but before COVID it wasn’t talked about, and it was just kind of like this silence of this evil secret in the medical field. And I felt, and I know this isn’t everybody’s calling, but I felt that it was my responsibility to talk about it and bring light to it, and to hopefully provide others with mechanisms to not go down that path.

Kevin Pho: All right, so you shared that powerful story, of course, about your father’s suicide. Tell us how that has informed you going forward, because like you mentioned, you’re the only other physician in your family. How did that change how you practice today, and some of the things that you’ve done professionally?

Katherine Twombley: It’s not a blessing, but it is a blessing on how it changed my mind frame. So I only take on things that I like or I’m passionate about. I don’t feel the need to say yes to everything. It has changed my perspective on how I take care of myself.

One of the things I talk about in the book that I think has been the biggest help to me is, whenever you take family vacations, especially if you have little kids, that’s not always a vacation. You always hear that phrase, I need a vacation from my vacation. So I’ve started taking more time for myself, in addition to time with the family.

And I think that’s where a lot of us have failed, in that we take care of our family, we spend time with our friends, we take care of work, but we don’t take care of ourselves. And so I’ve had more of a focus on myself since we lost my father.

Kevin Pho: One of the things that you mentioned is that you would only do things that you like to do, or things that you were passionate about. Now, you are chief of a department at a major academic medical center, and a lot of physicians through training, we’re not really conditioned to set those boundaries, right, to say no. And as physicians we pretty much say yes to everything. How difficult was it for you to really set those boundaries and only accept things that you were passionate about and liked to do?

Katherine Twombley: It was very hard in the beginning. It’s almost like an addiction, right? In the beginning it’s really hard to say no, really, really hard to say no. But the more I’ve done it, the easier it is.

It’s one of those things where you really have to put it in your brain and say, if this isn’t going to help with my career advancement or my personal knowledge, or whatever your goals are in life, then you’ve got to say no to it. Because if you’re the person that’s always saying yes and you’re doing a good job with it, you’re going to get asked to do everything. And in the beginning, when you’re young, you go, oh, I’m so honored that they asked me to do this. And you will get burned out by taking those over and over and over again.

Kevin Pho: Now, for those young physicians or medical students and residents, what kind of advice do you give to them? Because it’s a little bit of threading the needle, right? At one point they need to be able to accept everything that’s given to them, but sometimes that would lead to burnout. So for those people who are just starting out, how would you advise them?

Katherine Twombley: They need a good mentor, because I think the mentor is key to helping you decide what is important, what your goals are, and how to achieve those. I think in the beginning you don’t always know what you need to say yes to and what you don’t, so you say yes to everything.

But I think, through my career, I’ve had a life mentor, I’ve had a career mentor, and then I’ve had a content, like a nephrology, mentor. And I don’t think I could have made it without any of them.

And just because your mentor is that mentor in the beginning, you might surpass your mentor at some point and become a division chief where your mentor has never been a division chief, and at that point you have to look for a new mentor. But I think mentors are so important, and it’s just not focused on enough in academic medicine. They talk about it, but, yeah, you need a mentor. But no, you’ve got to go out and find that mentor.

Kevin Pho: Your book is titled “First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement,” and that obviously spans a decades long period of time in a lot of physicians’ careers. Tell us some of the key messages that you want readers to come away with after reading your book.

Katherine Twombley: So I look at physicians, there’s a couple of groups right now. There’s those that are planning to go into medicine or are already in medicine but early, and then there’s late career people.

The early people, I want them to read this book and learn that there are steps that you can take along the way that will make your life better. There are some pitfalls that we’ve learned from, that I learned from my father’s journey, that I had made some of the same mistakes and have learned that we don’t have to make these mistakes.

Number two, for the late career people, I want them to know you’re not alone, and that you need to ask for help. And we don’t need to lose more physicians than we already have. We lose 300 to 400 physicians a year, which is a whole medical school class, to suicide, and a lot of that’s probably underreported. We know that deaths are not labeled as suicide. So this is a huge problem, and if we don’t start speaking out on it and taking action, then we’re not going to get anywhere.

Kevin Pho: So let’s talk a little bit more granularly, certainly without giving away everything in your book. So you divided physicians into two groups, right? The early career physicians and the late career physicians. What kind of advice do you have for each group when it comes to burnout and obviously preventing suicide? So we’ll give some tips for each group that we can come away with.

Katherine Twombley: I think for the younger group, I think it’s important to remember that you’re not perfect. People who go into medical school are obviously high functioning, intelligent people, and they’ve always been the top of their class and always have perfect grades. And you get to medical school and residency and you’re now with a group full of high functioning, intelligent people, and you don’t have to strive to beat them. It’s not a competition. They are your colleagues. Work with them, support each other, and you’ll go a long way. And find a mentor. You’ve got to find a mentor to help guide you in this career.

For the late career people, I think we have to understand that the times have changed. The stories of, I worked before the 80 hour work week, and I did, so I get it. But we can’t use that as a means to tell the younger ones how they’re not doing what we did. Or we can’t look at it as, oh, they left at 5:00 and we have this interesting patient come in, they must not be that interested or motivated to go into this subspecialty. The older group needs to set the example for the younger group, and they need to take care of themselves and their families and their patients, but not lose your identity into medicine.

Kevin Pho: So as we talked about, again, you’re in a major academic medical center, you’re in a position of authority. How difficult is it to change that culture, that 24/7 culture of medicine? You see it from the inside. You have connections, of course, with both learners, physicians in training, and that older culture of physicians. How difficult is it to change that environment?

Katherine Twombley: Prior to COVID it was really hard. One of the good things that came out of COVID is people can work from home more, a lot more remote meetings, you’re not running everywhere all over the place. I think COVID brought to light how overworked we were, and how tedious and unnecessary a lot of the things we were doing. So I think that in and of itself has already changed some of the pace.

I think there’s a lot left, and I think there’s a lot of us that are advocating for more change. I give some examples in the book about professions that actually have restrictions on how many hours they can work without sleep, and physicians are not one of them. And so I think there are some things that are going to have to change. We’re advocating for it, but it’s going to be a long process.

Kevin Pho: So especially since COVID, of course, mental health in physicians have been at the forefront. Based on your observations, talk about how far have we moved the needle, and tell us how much more work needs to be done today.

Katherine Twombley: A lot more work needs to be done. I think a lot of places are talking about it and they realize it’s a problem, and physician burnout is definitely on everybody’s mind and everybody’s agenda. But I don’t think we’ve actually moved the needle in fixing the problem yet.

I think a lot of systems focus on, oh, we’re going to provide you with employee assistance 24/7, you can call somebody. But nobody’s really focusing on what got them burned out in the first place, and some of that is system level factors. And I think there’s a long way to go for government, pharma, insurance, hospital systems, everyone to realize that they truly play a part in this, and that the whole system has to change, not just the physician. You can’t take a physician in a bad system, fix the physician, and then all of a sudden they’re not going to get burned out again.

Kevin Pho: So give us some specific examples, maybe as it relates to your own department in pediatric nephrology. What would you like to see done to change the system that can address physician burnout?

Katherine Twombley: I would love to see prior authorizations go away. We use a lot of subspecialty medications in my field, and the majority of them have to have prior authorizations. And so I spend a lot of time doing peer-to-peer consults and talking with upset parents, because they know their child needs this medication and we can’t get it, and trying to find alternatives. And it’s just really frustrating.

And it’s really frustrating to the young ones, who didn’t realize that was even a thing in medicine. They thought they were coming into a field and would know the treatment and be able to give the treatment. And yeah, I would love to see a lot of these regulations go away from that factor.

Kevin Pho: So you talked earlier about wanting to speak out against, of course, physician suicide, physician mental health, and having it more discussed in the open. Talk more about those efforts, and why is that so important.

Katherine Twombley: I think it’s important because when my father died by suicide, I didn’t even realize that there were so many other physicians dying by suicide every year. I looked at it as an isolated problem. What was wrong with my dad? What was wrong with his mental health? And there were problems with him, don’t get me wrong, but this was not isolated to him. This is a systemic problem, or we wouldn’t be having 300 to 400 physicians die every year.

And that was the big deciding factor for me to tell the story. Because everybody’s experience with the death of a loved one, especially by suicide, is different, and so I’m not pushing others to speak out. I’m saying this was my journey. I felt the need to speak out. Maybe someone else doesn’t feel the need. But it took me 10 years to even start writing this book, to be able to sit down and talk about it now.

But I think those of us who can, we really need to talk about it, and not have this culture of silence around it, where somebody dies and you read the paper and you don’t even know why they died, if it’s suicide. And my dad’s obituary was the same thing. And I’m like, gosh, how many other physicians in the community would have looked introspectively if they had known that’s what happened? And so I just want to be at least one person who is speaking out and making it known that, yes, my father died by suicide. It’s not happy, but it happens, and it’s a big problem, and we need to tackle this problem.

Kevin Pho: How do you want us to remember your father?

Katherine Twombley: My father was an amazing man. I started doing medical trips to Guatemala at the age of 15, just my dad and I, because he always wanted to help everybody. He was a generous man, a kind man, a funny man. Everyone who knew him loved him.

And that was the other reason for writing this book. I didn’t want people to remember my father as the rural ER doc who died by suicide. I want them to remember my father as the man he was, and that he’s continuing to help people even after his death.

Kevin Pho: We’re talking to Katherine Twombley. She is a pediatric nephrologist, and her book is titled “First Do No Harm: A Physician’s Burnout and Mental Health Guidebook from Medical School to Retirement.” Katherine, we’ll end with some of your take-home messages to the KevinMD audience.

Katherine Twombley: So take-home is, I hope the book helps people. The take-home messages are, you are not alone, this is a systemic problem. If you’re having problems, please reach out and get help. But we all have to fight for change. We can’t accept that this is just how the system is. If you see something wrong that’s contributing to burnout, speak up, talk about it, let’s try to figure out a solution to it together.

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

Katherine Twombley: Thank you for having me.