Okay, I think we'll get started. This microphone is working fine. Is that correct? You can hear fine? Okay. I want to just make – my name, by the way, is Dr. Michael Myers. I'm the moderator and one of the speakers of the session this morning. This is an invited session, meaning that it will be prerecorded. And so not only are we asked to use the microphones, those of us who are speaking, but when we come to the Q&A part, please use the microphones in the aisle to ask your question or to comment. Let me start by just telling you that this is – as I just mentioned, this is a session that will be both live today as well as part of the virtual meeting next month in June. And there's been some changes in the actual abstract in that two of our original speakers are not able to be here. And they have both prerecorded their portions, but we'll only be showing the prerecorded part of Dr. Lyons' presentation this morning. And Dr. Reed-Siemens will be – prerecorded will be part of the virtual session, because thankfully, Ms. Betsy Gall, who you'll meet in a few minutes, has come to also speak. And so you'll actually have four presentations today, followed by ample time for discussion. And we're going to try to restrict all of our remarks to about 15 minutes each, and then we'll just go from one presentation to the next, and then, as I say, ample time for all of us to have discussion. And I think with that, I think that is enough about the introduction. So I'm just going to ask Dr. Termini, who will speak after me, but she's just going to introduce me. Thank you. Hello. Dr. Myers is a professor of clinical psychiatry at the SUNY Downstate Health Sciences University in Brooklyn, New York. He is a specialist in physician health. He treated his first physician patient on Christmas Day in 1970 during his residency. Thus began his 50-plus career trajectory looking after physicians. He lectures all over the world on this subject. He's also become a frequent blogger on physician health for both Psychiatry Congress Network and Psychology Today. He is the author or co-author of nine books, the most recent of which are Why Physicians Die by Suicide, Lessons Learned from Their Families and Others Who Cared, and Becoming a Doctor's Doctor, a memoir. Thank you very much, Dr. Termini, for the introduction. And I've also asked her to be the timekeeper, and she'll give me a sign when I'm kind of getting close to the end. The last thing in the world I want to do is violate the time commitments that I want everybody else to obey. All right. So let me tell you, these are learning objectives. So we're obviously hoping by the end of our 90-minute session this morning that you'll be able to answer these questions and certainly have a sense of why you've come today and what you've learned. And these are also available on the app. So let's start off with the word shame, which is part of the title of this presentation. And as all of you in this audience who are physicians will know that shame is ubiquitous in medical training and practice. It's been there for a long, long time. And as you know, it's allied with perfectionism. And we know how normative that is, that it's pretty hard to get in medical school and beyond without at least some measure of perfectionism. Teaching by shaming, those of us who are in education, we've been fighting this for a long time. And teaching by shaming is much less than it used to be, but unfortunately is still with us at times. Bullying and sexual harassment are concerns, of course. And these are all things that can impact, of course, on the trainee, whether this individual is a medical student or resident or beyond, you know, working in a medical setting. Shame, of course, associated with medical error, and there's a lot written on that subject. And of course, shame and mental illness in medical students and physicians, and this is why we've put this together this morning. So I'd like to break this down into interior shame. That's what rests within us, and we have our own measure of it, whether it's got to do with the way we've been raised, our family origin, and how much we've actually incorporated through our personal and professional life. But unfortunately, it's part of the culture of medicine as well, and we work hard to change that, and there's been big, big changes. As Katie mentioned, I saw my first patient as a resident in 1970, and we've come a long way since then, but there's still a ways to go. But too often, as I say, our profession is a partner in this process of self-repoach, and I think sometimes even our colleagues and perhaps ourselves, we don't even realize sometimes how much we are actually doing that, you know, with our colleagues, certainly ourselves, but our colleagues when they fall ill. And so for the individual, then there's this sort of sense of being deeply embarrassed, as I say, self-repoach, judgment, et cetera, and the result can be dangerous, and that's also why we're here today. So here's a conversation that I had with a patient, slightly disguised, a surgeon patient of mine who I had been seeing for about nine months, and she almost died from a near-fatal suicide attempt by overdose, and here's my conversation with her. I'm saying to her, she's just waking up, do you know where you are? She said, yes, I'm in an ICU somewhere, correct, do you know what happened? And then she said, I sure do. I took too many pills. I wanted to die. I mean, I want to die. To which I respond, I'm glad you didn't. I'm happy you survived. She says, you are? I'm so embarrassed, I feel ashamed of myself. Don't be. You're in a good place here. But he's judging you. The staff here just wants you to get better. She says, but I really blow it. What kind of surgeon can't even kill herself properly? Me, taking some risk and using, trying a bit of humor, remember, I've known her for nine months, so we had a relationship. I said to her, I didn't realize that knowing how to kill yourself was a requirement of the American Board of Surgery. I can still remember this so vividly. She's smiling slightly, says to me, like many surgeons, good one, doc. I say, get a bit more rest, then you and I have got some work to do. Your depression is still there, and it's got to be treated. We'll keep you safe here until you're feeling better. This is from a man who was not my patient. I interviewed him some years ago when I learned of his problem. And here he was a PGY-1 resident in internal medicine, and he had collapsed, and I think the word collapsed really fits into a recurrent depression, through the transition of going from medical school to his residency. He asked for my address, saying that he would send the chief resident over immediately. I had this thought that I was insulted. For those of you who are in training, or are training directors, or are chief residents, for instance, some people find this kind of strange. Why would he feel that way? And what it had to do with, I won't go into the rest of it, was that he felt that he had confided something in his training director that was so deeply personal, and he didn't know him that well, and he felt actually somewhat betrayed. And so it's not got to do with hierarchy, like how, you know, why didn't you come, or something. It had more to do with just this horrid self-esteem problem, in this sort of sense that now I've got to kind of tell my story to a complete stranger, or something like that. And many of you who work in the area of suicide, you'll know that ambivalence that our patients will feel at times. And just with all of that, then he just couldn't take it anymore, and jumped. Now this, fast forward now, many years, because he suffered a severe spinal cord injury, and is paralyzed from his chest down, that's a thoracic spine injury. But just three months ago, or two months ago now, he published an article in JAMA, neurology, about his situation. It's been many years. I have followed him, and I've been like a mentor to him for many, many years, and I'm just so grateful to him for doing that. And so he's now beginning to speak out, and talk with people in training, and our faculty. So I want to tell you a bit about the backdrop to this work. So it's now, in January 25th, I began interviewing, this is my post-vention research, survivors of suicide loss, physicians, and individuals who had a relationship with the person, family members, colleagues, et cetera. And I also interviewed a number of physicians who had attempted suicide, but did not die. And my small database, because I had a bit of a database, really blossomed, and it really grew because one interview led to another. And so as of this, so this is about a year ago, and I presented results of this virtually at the international conference in the UK. At the time of this, 51 physicians who had died, number of interviews I've done, et cetera, et cetera. So that just gives you a bit, and I'm not going to go into all the detail of my findings because we don't have time, but what I do want to tell you is this one, because this is really disturbing. So at least 15% of physicians who killed themselves, they had not received an assessment by anyone. Primary care doctor, psychologist, clinical social worker, psychiatrist, educator, no one. And that is really upsetting. I have a lot of friends who are oncologists. I've asked them, I said, have you ever heard of a doctor diagnosed with cancer who doesn't go to an oncologist at least once? And they may still kind of reject what the oncologist has to say, but at least they go forward because, see, they don't feel the shame and the stigma, or they don't feel the threat of their medical license being impacted by their reaching out for care. And we're going to hear from our speakers today that will really point that out very, very clearly. So this second bullet, basic education for families who are desperate to learn more. What can they look for? And you're going to hear from our speakers today about the importance of that in education, then also for physicians themselves. We're all mental health professionals here, mostly in this audience, and I think the imperative for us is to not forget about our medical colleagues trained in other branches of medicine that would really welcome just some of the basics of what to watch for in themselves if they should begin to develop symptoms. This is an example from my own practice, a psychiatrist patient of mine who took his life. And it was actually his medical student son who referred his father to me. The medical student had been a medical student of mine, and at the end of his clerkship he asked me if I would see his father, who he was really, really worried about, and I did. And so here we are now at my patient's memorial service and his son saying to me, my dad never really stuck to the treatment you provided for him, Dr. Myers, he just hated being a patient. He felt so ashamed, and I can remember this so vividly, he just, he was used to looking after patients. He just did not want to be, as he said, a mental case. Words used by a fellow psychiatrist, I feel like a mental case. That's his shame. I tried hard, but even my support wasn't enough. This is from a physician who picked up a copy of my book about why physicians die by suicide after he attempted suicide himself. So he sent me this email, you know, I get in touch with everybody who responds to me, so I've now been in touch with him. With the subject line, halfway through your book, I'm stunned, thank you, at the breadth of information I did not know. Needless to say, my impulsive, he refers to a suicide attempt as an event. Acted on in about 30 minutes. I'm healthy now with therapy and doing well otherwise. One thing that I've noticed over and over again is physicians' varying ability to cope with my event. So he lives in a small community, I won't name the state, although he has now kind of disclosed where he lives, but that's his story. But look at this. These are his colleagues. When I'm talking with someone and they figure out who I am, a wall goes up. What was a collegial appointment turns into an emotionless contact. I've become the thing that they don't understand and don't want to admit exists. Thank you for speaking out to all of us. This is shame in families who have lost a physician loved one to suicide. So these are the words of a physician who says he killed himself in 2008, okay, so that's a while ago. Funeral on a bright sunny day in August, but only two people from where he worked attended, so she thought, well, it's summertime, they're away on vacation. She was in a support group. Then she learned from Sam, who lost his sister, who was a dermatologist to suicide, that he noticed the same thing at her funeral. If she had died of cancer, they'd be standing room only. This is why we're here today. Thank you for joining us, and I'm delighted now to introduce our next speaker, Katherine. Did I make it okay in the time? Okay, good. All right, I want to tell you, because I have a little blurb about all my speakers, Dr. Termina is a PGY1 resident, just about finished her first year in psychiatry at Vanderbilt University School of Medicine in Nashville, Tennessee, and here's how I met her. I wrote her an email, dear Dr. Termina, I'm a specialist in physician health. Whenever a medical student or a physician writes a piece about their lived experience that I come upon, I write them to thank them for this important gesture. My live bio mission is the title of Dr. Termina's piece in JAMA in 2021, and I said to her, your paper is a gift to all of us in medicine. You're chipping away at stigma and making it easier for your brothers and sisters who are medical students and physicians living with a shameful secret to speak openly and with freedom. I'm saddened to read how you were discouraged in your personal statement from being transparent. That's her application, which she'll probably talk about. This is far too common. I'm on the Scientific Program Committee of APA. I'd like to talk to you about joining myself and two others in submitting an abstract to next year's meeting in New Orleans. It will be on this dimension of physician health. Let me know if you're interested in hearing more about it. Again, thank you so much for your story. Thank you for being here. Thank you. Hi, thank you, Dr. Myers. I'm Katie Termini. I, like you said, I'm a PGY1 at Vanderbilt University studying psychiatry. I did publish that piece, and I'd like to tell you about why and the experiences that led me to publishing it, and why I think this is such an important thing for us to talk about. I will admit that I don't have any visual slides or, like, any support. I really just want to talk to you about what I've been through and what I think that other physician trainees are going through, too. So I am a first-year psychiatry resident, and I want to discuss how the so-called hidden curriculum of residencies and medical training, including during medical school, impacts the well-being of physicians in training and begins instilling this sense of shame very early on with regards to struggling and with regards to mental illness. As an adolescent, and really through my early youth as well, I struggled with post-traumatic stress disorder, and it ended up hitting a point where I felt completely and utterly defeated. It felt like every day of my life was being eaten away by fear of my surroundings and by this sense that the world could never feel really safe to be in. It felt like my trauma was this grotesque, twisted monster that lived inside of me that was pulling me down and would never release me from its clutches. I felt completely and utterly hopeless and didn't see a life for myself where I would be happy. So at 16, I attempted an overdose and attempted to end my life. Shortly after, as is sometimes typical, I had regrets and ended up seeking medical treatment, and I'm lucky to be here and glad to be here. After that, I sort of treated that as a wake-up call. I started focusing more wholeheartedly on my own mental health and on overcoming that monster that had been holding me down. That whole experience, fighting that monster, seeing that I could defeat it, that I had the strength to do that, and I had the resources and support around me to achieve it, was life-defining for me. It gave me reason to live. It taught me confidence. It taught me resilience. Even though it's something that people have a lot of stigma about and that in our world there exists a lot of shame around, this idea of attempting to end your life and people's difficulty with understanding how things could get that bad, I didn't necessarily feel a lot of shame in my youth about it. I certainly felt regret for hurting my family in the way that I had, but on the flip side, it really became a core part of me growing into an adult and growing into the woman that I am, and it led me down a path that brought me to the life that I have today, and I love the life that I have today. During my undergraduate studies, I wanted to help individuals that were facing similar experiences, and so because of that, I ended up becoming involved in, this was a hotline for several years. In that program, I found this community of people who saw things the way I did, who saw suffering the way I did, is this very human, this very core part of being human, and that sometimes it leads people to the depths of despair, where they don't feel like there's any other way out. I found a community of people passionate about discussing and destigmatizing suicide, bringing it out into the daylight, rather than letting it fester in the shadows, where it only gets worse. People who, either by professional or personal experience, understood that suicide isn't a trope, isn't this thing to be stigmatized, it's not this maniacal or uncontrollable thing. It's also not a form of escapism that's meant to be romanticized. It's tragic and sometimes completely overwhelming, like you're being sucked underwater by a riptide, and you feel like you need to either take a breath or your lungs will explode at some point, but then realizing that there's no air there to breathe and that you're trapped. Despite it feeling like that, it's also a community that I found that knew that there is hope for people experiencing suicidal ideations and knew that there are ways forward. Although that hope may not be seen by the sufferer, I felt so much fulfillment to be part of a program and part of an approach that was meant to help people suffering see glimmers of hope. So it was during my work on the Suicide Hotline that I began to seriously consider a career in medicine and on focusing on helping people. In medicine, I really kind of expected to find a similar community to what I found at the Suicide Hotline, a group of professionals who had, based on their knowledge and understanding of mental illness and suicide, had let go of those biases and had put down the tropes about suicide and acknowledged it for what it really is. I got my first hint that that might not be the case when I was applying to medical school and was explicitly advised against discussing my personal experience with mental illness and suicide in my personal statement. At the same time, I was also getting this messaging and seeing this advice that talking about other medical anecdotes is encouraged during the application process. That really left a foul taste in my mouth. It didn't really make sense to me. I had really integrated my suicide attempt and my struggles with mental illness into this positive thing in my life and this driving force in my life, and so I didn't really understand at the time why it wasn't okay to talk about it. In the moment, I sort of put those feelings aside and said, okay, this is like the MCAT. It's one more hoop to jump through. I need to write a silly, lackluster personal statement and get into medical school. It'll probably be better. When I'm in medical school and really in this community, I can probably find people who view things like me and it will be better. When I got to medical school, however, I pretty quickly realized that there existed this so-called hidden curriculum that's sort of being talked about more now. It's the process by which medical learners are socialized into the cultural fabric of medicine. This curriculum is also sometimes at odds with the more overt or direct messaging from a structured curriculum. My school really very appropriately provided direct lessons on physician resilience and on physician suicide and on the fact that physicians are committing suicide at an alarming rate and that things need to be done to improve that and to improve physician mental health. However, I also heard physicians and attendings talk disparagingly about patients suffering from suicidal thoughts, casting doubt on their intentions behind coming to the hospital and at one point, an attending said to me, if I gave that patient a gun, he wouldn't do anything with it when discussing a patient in the emergency room with suicidal thoughts. This was the messaging that I and other medical students are getting. In the real world, in this field, this is the hidden curriculum. These are the messages that are at odds with what we know will actually help physicians in the future and what we know makes better physicians. I realized that these were people who didn't really understand how terrifying and hopeless living through suicidal thoughts can be or how the ambivalence around living can lead someone to seek help one day and then leave against medical advice the next day. And that lack of understanding broke my heart. I found myself craving that community I'd found in college where I could talk openly about my adversity and how it had molded me into the person I am. Instead, I felt like I was hiding this part of me and that part of me is a core reason why I'm a physician. I also couldn't help but noticing that there was this balancing act or these messages that were at odds between the curriculum I was being given and, like I said, the messaging I was getting in the real world. And it occurred to me that if I felt like I couldn't talk about my suffering that I'd been through as a youth, how could we possibly expect physicians who are currently suffering to ever speak up or ever feel safe and comfortable to get the help that they need? Thank you. I felt shame for having been through suicide in the first place and even more shame for hiding it because I knew that that contributed to this ongoing culture of silence and this ongoing culture of shame. So in my fourth year of medical school, I ended up taking a narrative medicine course and took that opportunity to write explicitly about this secret part of myself in an essay that I titled, My Lie by Omission. I was encouraged by my instructor, who's a wonderful mentor, to proceed with publishing, so I submitted it to the Journal of the American Medical Association, where it was published in July 2021. Encouragingly, the response to that essay and publishing it was overwhelmingly positive, although to be expected, given those cultural bits that I've explained before, there was a minority of less than positive and sometimes overtly negative responses. In particular, I had a mentor in medical school who very strongly advised me not to publish this essay at all, that it could permanently damage my career. And his concerns weren't unfounded. I think that his advice came from a place of concern for me and a place of caring for me rather than a place of attempting to stigmatize me. I think he saw the problems in our culture of medicine and didn't want me to fall on the wrong side of that. But at the end of the day, that added further evidence for why I felt the need to share my story. And by sharing it, I hope to open a space within our field for colleagues who are suffering right now to feel safe to come forward and seek help. The stigma against physician mental illness is salient and at odds with our recent drive to decrease the high physician suicide rate. A powerful way to combat stigma is by sharing and hearing narratives. I don't ask that anyone share their story before they're ready, but I do ask that every member of our profession be there to listen with empathy and without judgment when stories like this are shared. Don't give in to stigma that suffering physicians are permanently damaged or that they cannot appropriately perform their duties. Physicians deserve to be fully realized humans and suffering is part of humanity. I hope to someday see that trainees in our field can utilize personal narratives like mine to show their strength and resilience and their appropriateness to become physicians. Though we still have progress to be made on this issue, we're on a good path as evidenced by JAMA publishing essays like mine in the first place and that all of you here are listening with open ears and with empathy and that people like Dr. Myers are actively working to make change. Thank you. Thank you. Very nice. Thank you. Our next speaker is speaking to us by a prerecorded 15 minutes that I'm going to put on in just a moment, but let me introduce him, Dr. William Lyons, L-Y-N-E-S. He's not able to be here today, so I will show the prerecording. Dr. Lyons is a retired urologist living in Southern California. He's very busy as a physician author, especially several works of fiction, and he's become a physician burnout advocate and speaker. Dr. Lyons sent me a letter a few years ago about his struggle with depression and suicide and whether we might do some collaborative work. Indeed, we have a couple of podcasts, and he was a virtual speaker at APA's meeting last year as part of a session that we called the suicidal physician narratives from a physician who survived and the physician widow of one who did not. This included Dr. Linda Reed Seaman, who's also not able to be here in New Orleans, but her prerecorded portion will be incorporated into our virtual meeting on June 7th, 2022. Those of you who were here at the beginning are aware of that. Okay, so let me just see if I can get this going. Yeah. It's on. Yeah. And I'm here today to talk to you about my personal experience with physician burnout, mental illness, suicide, and shame associated with these conditions. I went to the University of Texas Medical Branch for my medical school degree in 1981. I did a urology internship and residency at Stanford University Medical Center from 1981 to 1987. In 1987, my wife, Patrice, and my three children, Chris, Alex, and Nick, and I moved to Southern California and I began practicing with Southern California Kaiser Permanente Medical Group in Riverside, California. Now what I'd like to concentrate on is this period of time from the end of my residency, 1987, until my retirement in 2003 when I was practicing urology. I can divide that period of time into two distinct eras. The first era was I had a happy, busy, successful life in urologic practice from 1987 to 1998. However, in 1998, something occurred and I began what I call a downward spiral into darkness, which is sort of a code for suicidal behavior. I call it my demise. And it began in 1998 and it ended with my retirement in 2003. So for this first era of 1987 to 1998, I had a very busy private and professional life. I married, as I said, raised three sons. We were active in the church and community. We were very involved in local sports. And I might just emphasize again that I had a very, very busy urologic practice. This is a castle playhouse that we built in the backyard. My kids were really at that time into fantasy adventure, Pirates of the Caribbean, Princess Bride, and so forth. And they asked me if I could put them in a story, actually. And I began in May of 1990 writing what became a novel about a fantasy adventure story set in medieval times with my kids and my wife and even my pet dog as the major characters. And this is just a slide which shows that I would write often at daytime during lunch and then bring home the pages and read them at bedtime for my kids. And they were very helpful in suggesting various changes and so on. The other thing that I did is I tried to involve my family as much as I could in my urology practice. And I would bring my kids on rounds on the weekends with me, and they would come home like here with articles from the hospital, head caps and masks and so forth. And this is the last slide of my family, which is 1989. And this is Chris on the left of the party hat, my wife Patrice in the middle with Nick sitting on her lap, and Alex on the right sitting on my lap. Let me just go back another. The story that I wrote with them ended up being a novel called Pirates, Scoundrels, and Kings. And it was published in 2012. Now in 1998, as I said, there was a life-changing event which occurred. What happened is we were on a family vacation out of the country. And when I came back, I just didn't feel well. But I didn't do anything about that, which is very typical of me and I think typical of physicians in general. We tend to treat ourselves until I woke up in the middle of the night one night with shaking chills and fever. And literally within two hours, I was being intubated for respiratory failure and septic shock in the intensive care unit at Kaiser Riverside. I spent six weeks in the intensive care unit. I had all the manifestations of septic shock. I had to have chest tubes. I had a tracheostomy. I ended up losing 40 pounds during that illness. Now I survived. I then rehabbed and went back to work 10 months later. Unfortunately, in April of 2001, I had a snowboarding accident. Again, this is on a family vacation. There's sort of a pattern here. But I sustained multiple facial fractures. I was in intensive care unit again. I had five facial operations. I had to have a tracheostomy again. My jaw was wired for a month, and I lost 40 pounds again. Again, I survived this event and rehabbed, this time returning to work two months after the event. So the situation is that I had several catastrophic medical surgical events occur. I would rehab and return to work. When I returned to work, however, I was not the same. The main problem was a horrible depression. I had depressions before in my life, but nothing like this. I was depressed beyond my ability to cope. It was black. It was grim. Day after day, day after difficult day. I had anxiety problems as well. I think that you age when you go through events like this. I had poor response to stress, lacked confidence, and importantly, the excitement from my practice was gone. I regularly started seeing psychiatry, and they feel that I have Bipolar II Affective Mood Disorder, and I began on the wonderful world, I call it, of antidepressant mood stabilizer therapies. I think that I've been on over 30 different drugs, maybe 100 different combinations. I also was introduced to electroconvulsant therapy, electroshock therapy, and I've had over 30 of those treatments. So the situation is that I wasn't feeling well in my practice, and because of depression and the other things that I've mentioned, and just as a timeline, that began in May of 99 when I returned to work from septic shock. So day after day, I struggled, always thinking that I was going to get better if I just worked harder, but I didn't, and in May of 99, I decided to try to take my life. This is a poorly thought out, very quick attempt. I took an overdose, and I recovered very easily. I didn't tell anybody that it was a suicide attempt, except for my wife. When I went back to work, as I said, depression, anxiety, and so forth, day after day, I just could not cope. I was depressed beyond my ability to cope, and so in August of 2002, I decided to end my life. Now this was a well planned out, very serious attempt. I went to a hotel, and locked myself in the hotel room, proceeded to take a massive overdose. I took over 100 different tablets and medications, and I laid down on the bed in that room to die. When I was found, I was comatose. I was taken to a local hospital. I was intubated because of respiratory failure. My family was called in, and they were told that I would not survive. I did survive, however, and I ended up in a locked psychiatric ward, where I began getting the electric convulsion therapy. Now you might say, why would a person in this situation not want to retire at that time? But you have to remember, I was only 48 years old. I had a family to raise, and perhaps more importantly, I liked being a doctor when I was feeling well. I thought that if I just kept trying, that I could get back to that situation. I really had to beg the hospital wellness committee to allow me to practice again, but they did. I went back to work, and unfortunately, the black demon of depression still covered me. Day after day, it was difficult. Just going to work was difficult. In September of 2003, I decided to end my life again. Again, this is a well thought out, planned suicide attempt. I went to my office on a weekend. My office was in the corner of the urology clinic. I remember going there, and it was black. It was isolated. There was nobody there. I went into my office, and it was cold. I remember looking at my reflection in my medical school diploma, and ironically, the glass was cracked, but importantly is the fact that looking at my reflection, I felt so disgusted about what my mental outlook on life had become. I lacerated my wrist, and I laid down on the floor of my office to die. I fell into a deep sleep for perhaps four or five hours, and during that period of time, I bled and bled and bled. I lost maybe four or five units of blood. When I woke up, the bleeding had essentially stopped, and I could tell because of my training that I wasn't going to die. The question is, what would I do? In just a few hours, the clinic was going to begin. There would be staff there. There would be patients. I very reluctantly called the hospital operator, described the situation, and with great humiliation and shame, I was admitted to the hospital. I had surgical repair of my wrist, and I ended up taking a disabled retirement in 2003 which I've been on since then. Now just briefly how my life has gone since retirement. I struggled with my life and self-worth. I had obsessive suicidal thoughts but very importantly I didn't feel like I was a doctor anymore and this was very important to me. I really related to it was part of my nature. I write fiction as I mentioned before and I went to a writing seminar in Taos, New Mexico where I met a physician who had a story not unlike my own and she had written an essay published in the Annals of Internal Medicine in which she confronted her problems for the world to see and she recommended that I do that as well and so I wrote The Last Day which is an essay chronicling my last day of medical practice and it was published as well in the Annals of Internal Medicine in 2017 and I had similar therapeutic benefit. Since then I've been an advocate for physician burnout and suicide and a speaker and I had tremendous improvement in my mental outlook with life. Now I've been asked to talk about what were some examples of shame that I felt associated with mental medical illness and I pulled out three what I call milestones of shame. The first is when I was returning to work after septic shock I went to the physician's office who was writing my offer of orders and I told him that I wasn't ready to go back to work. Immediately over his countenance became a countenance of disgust and anger and I was fairly upset with that but what I was really upset is I hand carried my written medical record to my next appointment and this physician had written in the medical record that Dr. Lines must return to work without excuses. Now I was not proposing any excuses this guy I thought was my friend he was a partner and I was very upset with that. The second milestone of shame is when I mentioned that I had taken an overdose after I'd taken an overdose for my second suicide attempt the cat was basically out of the bag. Everybody knew that I had tried to commit suicide and I went before the hospital wellness committee and as I mentioned I literally begged and cajoled them to allow me to go back to work. This was a very shameful episode in my life and the third milestone of shame is with my third suicide attempt. Remember that I was then admitted to the hospital that hospital was Kaiser Riverside where I had practiced for 16 years. I knew everybody from the cafeteria workers to the operators and I was tremendously shameful, humiliated and this is the third milestone of shame. Shame associated with mental illness is endemic in our medical community and in fact in our world. It does nothing to further the treatment of this condition. Stories such as mine litter the noble profession of medicine. I hope that forums such as this will improve the treatment of physician burnout, suicide and the shame which is associated with mental illness. Thank you. So as I mentioned to you before Dr. Lyons, he'll be part of the virtual program and will be able to take questions at that time. Ms. Betsy Gall is a graduate of the University of Minnesota with a background in design and interior decorating. She's now a realtor in Odina, Minnesota. She reached out to me by way of email about a year ago in early May of 2021 and told me about the tragic loss of her husband Matthew to suicide the year before. She graciously participated in my suicide aftermath project which I was telling you about earlier. We've kept in touch and when Dr. Reed Seaman was unable to come to New Orleans, I contacted Betsy and she's come to our meeting with her son who's with her here today to share both her story and the fine work that she's been doing to advocate for physicians taking better care of themselves and fighting the barriers to getting treatment for psychiatric illness. That's it. It's about 3 a.m on Thanksgiving morning. The bedroom is dark and I'm scared. My heart's beating out of my chest. I woke up to Matthew saying, what's going to happen Bets? Oh dear lord, I thought to myself the sleep medication didn't work. My husband Matthew is very sick. He was suicidal last night. Last night Matt was in our master bathroom. He was wearing a blue dress shirt. My husband always prided himself on dressing nice and yesterday was no exception. Matthew kept repeating, it's over, it's over. I said Matthew, you are a child of God. Chris, my brother-in-law, was desperately trying to pry open the bathroom door. The look on Chris's face was panicked and pained. Sweat beads were rolling down his forehead. He didn't have half the strength of my husband. Matthew is my muscular, powerful, brilliant partner of 20 years. He has the strongest mind and the strongest body. How did we get here? I thought to myself. Grady is suddenly walking by. Grady's my beautiful 17-year-old son. Grady, dad has a gun. Can you help? I pleaded. Grady walks up to the door and says, dad, I understand how you feel. Please don't do this. Open the door. Enough, I scream. Chris looks at me with a petrified look on his face. Matthew, this is over, I yell. Grady pushes open the door and gets a gun out of his father's hand. I'm floating. I've been floating for the past three months. I feel like I'm in a made-for-TV movie. God is here though. God is with me. What in the hell has happened to my husband? We've only been in Charlotte, North Carolina for three months. What in the heck has happened to our perfectly normal, beautiful, all-American life? Matthew, you're going to the ER. Chris, Diane, and Grady, they're taking you to the ER, I state. I can't go. I'm exhausted. Matthew hasn't slept for more than three hours a night for the last few months. Therefore, my sleep has been irregular and cut short as well. Tomorrow's Thanksgiving and I'll have a lot to do. I've been fighting for Matthew since mid-August. The oncology practice that he joined, it's not what he thought it was going to be and it's contributed greatly to his stress. Everything that could go wrong has. Off they go to the ER. They're taking my husband, a physician who has never suffered from depression or even believed in depression for that matter, to the ER because he was suicidal. Matthew Taylor Gall, age 49, was threatening to kill himself and I have to ask myself, how God? How did this become my life? Hi, my name is Betsy Gall and I'd like to thank you all for being here and open to listening to my story. I'd also like to thank Dr. Myers for inviting me to speak. While I'm quite honored, it's hard. The subject matter, it's tough and unfortunately, as you heard, it's deeply personal. What I just read to you was my journal entry from November 27, 2019. But let me back up. I met my future husband, Matthew Gall, in 1998. We were both living in Chicago at the time. Matthew was doing his residency at UIC and I was working for a cool hip design firm in the city. I remember thinking to myself, I'd never quite met anyone like Matthew Gall. He was unique. He was full of energy in life and I could tell instantly that he had a huge heart. Matt was self-confident, extremely driven, and very happy. As we got to know each other, he told me how he knew he wanted to be a doctor by the time he was three years old. He felt it was his calling. He wanted to help people. Matt was prom king at his high school, captain of his high school football team. He played rugby in college and I'd like to note that he had nine concussions over his lifetime. Early on, Matt had never faced a medical emergency over his lifetime. Early on, Matt had never faced much adversity other than getting waitlisted to med school. When we met, Matt was doing a super intense surgical rotation. He'd work 16-hour shifts and then be off for eight and then repeat. He kind of had a green tint to his skin and dark circles under his eyes. However, Matt didn't let work get in the way of having fun during his rare free time. He was a guy who didn't waste one single minute. Matt's motto was, we got to get it all in. Matt and I loved going out to new restaurants, mountain biking, skiing, and he was passionate about football, particularly the Pittsburgh Steelers. I quickly learned that the first stressors of becoming a physician are one, actually getting accepted to med school, and then two, figuring out how to pay for it. Matt and I got married in 1999 in my hometown of Udina, Minnesota. It was a beautiful wedding on a picture-perfect day and I remember thinking to myself, I'm going to have the best life. We moved back to Minneapolis after Matthew finished his residency and he took a HEMOC fellowship at the University of Minnesota. I think at this time he was making about 30 grand a year, which was a big step up from his $18,000 a year resident pay, and we had a ginormous medical school debt hanging over our heads. Neither of us came from money, so Matt was moonlighting on the side so that we were able to make ends meet. The guy worked all the time. After his fellowship program was complete, Matt accepted a position at Minnesota Oncology, a large, prominent private practice group. He became a partner at MOPA, as it's called, after two years. It was then, finally, at the age of 32 that his hard work started paying off financially. The group was doing very well and life was really good. We were able to pay off med school, we built our dream home, had three healthy children, and eventually we were even able to buy a small lake home. Matt took on various roles and positions over his tenure at MOPA. He served on the Board of Directors, he was on the Cancer Committee, the Political Action Committee, the Finance Committee, and he was Chief of Staff at Ridges Hospital. Matthew worked really long hours. He took call at least two to three times a month during the week and probably every sixth weekend. Around 2013, the group's salaries started declining and that stressed Matt out. His group was partially production-based and Matt had always been a top producer. He prided himself on efficiency and getting stuff done. Pressure was on to see more patients in a shorter amount of time and when Matt would get rushed, he could become short with people. That didn't go over well with patients and he heard about it. In 2015, MOPA set him up with an executive life coach to try to help Matthew better balance his work life. Matthew was embarrassed about this. He didn't like showing weakness of any form. After all, that is how he was trained in med school. Pressure from competitors was on too. Medicine's a big business and Minnesota Oncology was always a target for hospital takeover. Matt didn't like that and thought being private practice was best. Matt was especially annoyed at hospital administrators and insurance companies that dictated how he provided care. He was, after all, the doctor that went through a total of 14 years of schooling after high school. Learning new EMR systems and studying for board exams weighed on him but I think what was most difficult was losing his patients to cancer. Matthew's patients meant everything to him. His heart ached for every family left behind. I sensed he had a feeling of guilt with every single patient death. I often wonder what that does to a kind compassionate human being such as my husband. As the years went on, I noticed Matthew's perfectionism was getting worse. We always joked about the lawn care. He was over the top with that. He spent countless hours on the lawn. In 2018, Matt's job in Minnesota was getting more and more stressful. His mentor and partner was getting ready to retire. Matthew received a death threat from the son of a deceased patient. This disgruntled person also wrote to the Minnesota Medical Board. Matt was distraught over this. Matt came home after a particularly difficult day and said, I love my patients but I hate my job. And I looked at him and I said, sweetie, there are a lot of other jobs out there. I found a recruiter for him the next day. Matt landed on a small private practice in Charlotte, North Carolina. I was sick of Minnesota winters. Our oldest son had struggled with bullies at school and I just thought a fresh start for everybody would be great. Matthew was promised a very large potential salary and we thought maybe the stress would be less with a smaller private practice. We were all super excited about the opportunity. So in August 2019, we moved to Cornelius, North Carolina full of promise and hope for a brighter future. Everything was going good for about a week and then our world started unraveling. It was like God wrapped his arms around me and whispered, buckle up, Betsy, because you're in for a wild ride. I started journaling every day. October 27, 2019. The first week here in North Carolina was promising but then Matt realized that this move was a huge mistake. Career suicide, he says. I've never been around a depressed person. It's not fun. He can't do anything, not the lawn. He won't grill. He won't even go for a bike ride. I have to drag him to church. There's absolutely no joy. I try encouraging words and urge him to get help but nothing happens. So now I'm praying for a miracle. I've tried to get Matthew to spring into action and look for a new job but honestly, I don't see it happening. We have three teenagers. Not sure what I'm gonna do. Matt's problems seem to be deeply seated. He stopped sleeping. He ruminates about his previous job, our old house and our old life. I think he feels trapped because of his non-compete here in North Carolina and his non-compete back in Minneapolis. He is full of regret. He loves his patients so much and he's constantly talking about their care. I guess I never understood how much pressure he was under all the time. November 6, 2019. Philippians 4 through 6. Do not be anxious about anything but in every situation, by prayer and petition, with thanksgiving, present your request to God. I'm trying this but my heart is racing. Matt goes to work. He comes home and he lays on the couch. This is so out of character for him. I'm scared for him. He has the weight of the world on his shoulders. I pray he doesn't harm himself. I've had awful thoughts of death and dying lately. I can't shake them. I truly believe Matt just needs to get out of this job. We need to get back to Minnesota. November 19, 2019. A guy friended me on Facebook. I went to high school with him but I don't know him. He's an anesthesiologist in Minneapolis. I accepted his friend request while lying in bed next to Matthew. Oh my gosh, his post. He's going to give a talk on physician suicide. What the heck? You mean this is a thing? I can't stop shaking. I leaned over and I asked Matthew, who was just staring at the ceiling, did you know that doctors kill themselves a lot? I mean I can't believe it. They're doctors. Is this a thing? Matthew simply nodded. Oh my god, he actually knows this. My heart is sinking. November 24, 2019. Dr. Foley, a friend of Matthew's in Minnesota, prescribed an antidepressant for him. Ambien too. He won't take them. November 25, 2019. It's not a good day. Matt's parents came to town for the holiday. Matt's not happy about his parents being here, which is so strange. He's always been so excited to see his parents. I talked to Dr. Foley this morning. He said again that Matthew needs to see a psychiatrist, take the antidepressant. He needs to exercise and sleep. I can't get him to do any of these things. It's beyond frustrating. I did talk to Matthew this afternoon and he was getting through his day but he said he was having trouble with his treatment plans. Matthew said, I don't think I can be a doctor anymore. Okay, what the heck? Okay, well you're super smart. I know you can figure out something to do. It's a job. There are many of them out there. I know if he could just sleep for a good solid week or two, he'd be able to think more clearly. It's his brain. It's not functioning right. 5 30 p.m. Matthew's parents, my brother and sister-in-law, Chris and I and I spoke to Matthew about the fact that he needs help. Sitting in our living room, Matthew kept saying something to the effect of, I can't take medication because of the side effects. I can't see a psychiatrist. I could lose my medical license. Matthew has a vacant look in his eyes. Will Matt lose his medical license? I don't know. His whole identity is wrapped up into being a doctor. I don't know anything anymore but we all agreed he needs to quit this job. Chris and my father-in-law took all the guns out of our house. I had no idea we had so many guns. Matthew was lying on the bed afterwards and he's staring at the ceiling. He was upset and muttering they took my guns. Matthew, this is temporary, I said, and just until you get better. I don't understand him. I can't seem to reach him. If he'd just listen to us and get some sleep, he'd be able to think much clearer. November 26, 2019, Matt tried not to take his medication but I made him. I'm scared. I contacted our financial planner. We have money in the bank. We're okay. Our life coach is out of town. I need to find Matt a psychiatrist and quick. I can't believe this is my life. November 28, 2019, Matt shot himself. He was out of his mind. He came home from the ER last night. They gave him a sleeping pill but it didn't help. He was sad here. I wanted to take him to the hospital this morning but he wouldn't get in the car. He didn't want to go. He was so strong-willed. I'm mad because he could have gotten help. He was helpless without hope. He refused to help himself. Why? I'm thankful to the Cornelius Police, the University of Wyoming, Grady got his acceptance letter today. I'm thankful for the sunshine, leaves, and people in my house. My life has been forever changed. It's Thanksgiving Day for the love of God. When the police arrived, I just kept talking, talking, talking. I couldn't stop. I kept saying, who will take the kid's tubing? Why am I repeating this question over and over again? I asked the young police officer if Matthew really was dead. He told me yes, it was true. I grabbed him. No. He helps people like you, sir. Doctors kill themselves a lot. I guess I didn't know that before. I wanted him to get better. I thought one day he'd just snap out of it. I fell to the floor in this officer's arms. He held my head in his lap. I saw the tears in his eyes too. I'll never forget him. I called Chris and Diane and they came over with Matt's parents. Pastor Paul and Stacy from Grace Covenant Church showed up. It's early on Thanksgiving Day. I can't believe they're here praying with me and the kids. We sat at the kitchen table and my mind was just racing. Oh my gosh, what will people think? My new neighbors, all of our friends, and Matthew's patients. Matthew was loved by so many. I feel guilty and shameful. I cannot fully grasp what's happened. There's deep anguish in my heart. I'd left a note on the kitchen counter. It said, kids, I'm taking dad to the hospital. Be back soon, XO mom. I never got him into the car. I'm so tired. I've never felt such exhaustion in my entire life. I'm floating. I feel like I'm in a made-for-TV movie. I don't like this movie. Turn it off. My life is over. Can't believe my powerful, strong, smart, life-loving husband is really gone. Mental illness is a disease like cancer, and it has a death rate. It's the 11th leading cause of death in the United States. Doctors kill themselves at a higher rate. It's been known for more than 150 years that physicians have an increased propensity to die by suicide. Exact numbers are not known. It's impossible to estimate with accuracy because of inaccurate cause of death reporting and coding. The number most often used is approximately 300 to 400 physicians a year, or perhaps a doctor a day. Of all the occupations and professions, the medical profession consistently hovers near the top of the occupations with the highest risk of death by suicide. Now I know why Matt wouldn't seek help. There's a stigma surrounding mental health issues, especially for our physicians. Our physicians need to be able to safely and confidentially ask for and receive mental health care. Let's face it. Modern medicine is broken, and it's the system that's the problem. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Hi. My name is Linda Seaman. I'm a family practitioner who practices palliative care, and I did do emergency medicine the first 20 years of my life. I'm here today to discuss the stigma and association of shame when it comes to the contributions to the physician's suicide epidemic. My husband was an ER physician for over 33 years, and we were married 30 years. He took his own life two years after his retirement, actually under two years. So I learned a lot along that journey prior to the journey of his beginning what I call insults and assaults that came. But I also have learned a lot since his death, which was three years ago. So I'm here to share that. Last year for the American Psychiatric Association, I told Matt's story, and I do want to refer you to the article that's in the resources. It's called Breaking the Cloud of Silence, written by Alicia Gallegos with Medscape. And she did a really good job. I was very raw at the time of that article, and I've grown a lot in my grief recovery. And I've learned a lot of things that I hope will be helpful. This year's focus isn't so much on all the details of the story, though I will be sharing pieces of it. But I want to focus predominantly on how powerful stigma is, and how powerful stigma leads to shame, and then how shame precipitates mental health deterioration. In physicians, I believe it's a fairly unique condition and evolution. Because of the culture of medicine, we are trained not to whine, not to really have too many emotions. We have to perform. And I think I speak predominantly from emergency medicine focus, which is what my husband and I both did. So I believe the sharing that he and I had as a couple and as friends in this journey was amazing. But there were downsides to it as well, because we absorbed a lot of each other's stress. And that clearly was part of this story. So number one, let me just say that shame is very real. And shame is used as a tool these days by regulatory agencies, like the medical boards that license us. It's used by hospital administrations and corporations. They shame you into saying you're not productive enough. You're not doing this right. You're not making enough money for the mothership, et cetera. And I'm here to say today that we need to push back in the House of Medicine, because there is no room for shaming us and no reason to be shaming us. The second component of shame comes from the stress of litigation. I particularly saw my husband, who was brilliant. He was well-boarded and trained in internal medicine and emergency medicine. And he ended up deciding to retire in 2017. The first month he retired, he received just a letter of investigation stating that a complaint had been filed for, quote, unprofessional conduct. There were no damages, and he didn't really have the whole complaint. And so he continued to just appeal and correspond with the board. What happened a year later is that the harassment continued. They moved him based on one peer review colleague who had sent in a report as an expert witness, who happened to also be a lawyer. Based on just one report, they moved Matt from an investigation into a disciplinary mode. This was not transparent. And so here is my husband, who is Phi Beta Kappa, Stanford graduate, always been really impeccable in his clinical skills, wondering why he's being disciplined for a patient complaint. The board sent a medical stipulation. Well, they call it an informal stipulation. And my husband would not sign it, because it was, quote, as he said, fodder for a lawsuit. And it was. I read the report. And it was not even properly peer reviewed. There was no fair balance to the descriptions. So Matt just said, I'm not going to sign this. Well, the medical board didn't care. So what do they do? They put an article in your local newspaper. They shame you, saying you're being investigated. And then they not only do more than that, when Matt decided to give up his license because he was retired, they put another article in the paper saying, your license has been revoked. Another way to shame you. There is no reason to be reporting to your local newspaper anything like that. This is confidential information. If you ask the medical board, they'll tell you, oh, it's in the name of public safety. I mean, he's retired. And he gave up his license. So I just want to point these details out, because there is no virtue to it. And we need to push back. Secondly, after Matt did revoke his license, he was shamed even more. All of a sudden, he gets, of course, reported to the National Data Bank. But more than that, the board asked for a paper copy of his license to be sent back. The paper copy. They don't need the paper copy. He got letters from the American Board of Emergency Medicine and the American College of Physicians, the Internal Medicine Board, saying you can no longer be board certified, even though he currently was, because you now no longer have a license. I mean, the amount of intentional shaming was horrific. So what does that do to a physician? What would that do to you? It makes you retreat. You become more isolated. You're afraid to talk to anybody. And in fact, it deteriorated Matt's mental health. In fact, December of 2018, after the hearing, where he volitionally said, I don't need my license. I don't need to make this all go away. I'll give it up. And they did. And his defense attorney poorly advised him, because that stipulation did become public record and did become fodder for a lawsuit. So here's a person with no damages who's really just upset, who's now got her fifth attorney. Alleging that Matt is unprofessional and tried to harm her and all this stuff. None of it made any sense and was not factual. But the truth be told is Matt's mental health went from feeling, OK, this is going to go away, to, ah, now I've got this lawsuit that I have to deal with. And in emergency medicine, in many fields, you can expect to be sued these days. It's just, unfortunately, a component of the American culture of greed and blaming and whatever else goes into that. But Matt became very, very depressed. He ended up spending a month in our local psychiatric ward, which was an absolute horrible experience and also full of shame. There were two psychiatrists in our town who did more administration and oversight. And when I approached them to help take care of Matt while he was in the hospital, they basically said, we don't do that. We just oversee the nurse practitioners and the mental health workers. And they said, but my husband is a double board certified internal medicine ER doctor. He is not your average patient. Bottom line, it was a horrible experience. Matt called it in his journal, quote, boredom hell, unquote. No exercise, no real therapies. The medications didn't work. He got worse. And finally, by the end of December, he said, I just got to get out of here, Linda. This is horrible. And not only was it shameful to him, he wouldn't let colleagues or friends come visit because here he is in this room with really a lot of people who did need to be there, who were not safe. And in fact, he had a woman who entered his room several times. They finally had to take her to a different ward because she was harassing him. And she had, I don't know, bipolar or something. But this is the kind of stuff my husband had to endure. And it was very, very upsetting. To end it, the discussion on his story, the physician refused to also support Matt. He evolved into a refractory depression with anxiety off the wall, worrying about the deposition now. And when I asked his outpatient telemetry psychiatrist to help protect Matt because I didn't feel he could defend himself properly, he was clearly very, very depressed and not making sense to me. He refused, said, I just don't do that. And I said, well, if you don't do that, who does? He goes, well, I would talk to your family doctor. So again, Matt was thwarted in his efforts. So how in the world can a physician recover from all this stress, not only the licensing investigation, the litigation, and the lack of psychiatric care? So I want to make a plea that, number one, we have to take care of ourselves. Corporate shaming, regulatory shaming, it's part of their game. We have to take care of our own house of medicine. And I want psychiatrists to please consider opening their doors and having physician colleagues in their practices. You understand. You get it. You've been through the training. Number two, you have to be able to find a physician coach or at least a safe ring of colleagues. And I encourage medical students, residents now in my teaching role, to look for that all through their career. I do not trust the corporations. Don't trust a hospital wellness committee. They're just looking for information. So please, go ahead and cultivate your own peer-to-peer support. The pandemic has really brought this out. There has been so much stress over the top. I mean, we do a stressful job as it is. And the chilling effect of the recent decision by the nurse at Vanderbilt being criminally prosecuted, I mean, it is just horrific, the stress that's out there for people trying just to take care of patients. And that is why we went into medicine. So let me encourage you to push back, to not accept the shame into your arena. Stand tall. And we need to try to change the processes that are out there. There is no reason to get your name in your local paper. There is no reason to get a personal, I mean, a paper copy sent back. There is no reason for a lawyer to talk at you and interrogate you during a deposition that makes you feel like you're a worthless dog. That is unprofessional conduct. And if we did that to our patients who are overweight or have an addiction, we should get our license revoked. We need supportive fact-finding environments. And we don't have that right now. So let me just wrap up and say, my husband took his own life 36 hours after that deposition. When he came home, he was not himself. He did not feel relieved. I did. He says, there's just going to be more of the same. Linda, I have psychic pain. This pain has got to stop. I need help. And I said, well, we need to go get you help. And we'll drive to the West Side, some of the bigger institutions. So we called his outpatient therapy psychiatrist. And you know, two calls from me, one call from Matt talking to his secretary. We never got a phone call back. And Matt took his own life 36 hours by hanging himself on my gym set with his own belt. It was so tragic and so not necessary. So I encourage you, stand tall, push back. Let's get the House of Medicine in order and protect ourselves and create safe havens for ourselves. Thank you. Thank you to everybody. Thanks for being here. So that's the end of our formal presentations. And we have until 930. For those of you who came in after the introduction, this session is being recorded. And if any of you have questions, and I hope you do, please use one of the microphones. And we will from here, too. Good morning. Good morning. Thank you so much for sharing your stories. I really appreciate it. And I'm kind of overwhelmed because I feel like there's so much to say. Excuse me just a moment. Are you able to hear at the back? OK, good. But I guess from a practical standpoint in terms of how we do provide that space for physicians to ask for and receive help, I work in eating disorder treatment. And we have a policy around folks being in recovery before they come work for our institution. And on the one hand, I can see where maybe the origin of a policy like that is meant to be protective in terms of somebody taking the time to actually work on their recovery. And I think we can all recognize that doctors aren't so awesome at taking time for themselves. On the other hand, it's a huge sort of a front to somebody's self-actualization and being able to say, I know where I'm at in my recovery, and I have my folks that I'm seeing. So I guess, Dr. Myers, for you, I wonder what programs you think work well in terms of helping support physicians when they are getting care and being able to return to training or to practice. Sure, OK. Thank you for your question. It's a big one. I think I'll just make a few general comments. I mean, we could start sort of at one level. I have been an advocate through my entire career for all physicians to have a primary care physician. OK, and start there. But as we know, many physicians don't. And also, it's not just about us. Maybe just not taking the time or trusting or whatever. It's actually trying to find, sometimes, primary care physicians who are not only perhaps taking new patients, but they're comfortable looking after physicians as patients. But that's the one thing is that way, then, we get away from that old business of actually treating yourself or making a self-diagnosis or things like that. And I think, in that process, you actually learn to actually be a patient, to entrust someone with your care. But as I say, that's really a hard issue for a lot of people. In more crisis-type situations, of course, then that's really different. One of the things we do often talk a lot, of course, is about our local resources. But that can be difficult as well, because sometimes physicians don't trust anonymity. And that could start right at the medical center itself that has services available. And it extends all the way to 1-800 numbers. There's the National Suicide hotline. And then also, at the beginning of the pandemic, there's something now called the National Physicians site, something like that, support site. It was started by two or three women physicians who volunteered. And now they have something like 750 or 800 psychiatrists across the nation who volunteer their time. It's not 24 hours a day, but it's about 18 hours a day, seven days a week. And I know physicians who have used that hotline, even though they have local resources, because they really feel that it protects their anonymity, that sort of thing. And so, I mean, those are just some of the things. The most important thing, of course, is for people to reach out. One of the things I just want to mention about training is that we also have a lot of resources now. And I'm delighted to see Dr. Christine Moutier in the audience today, who is the chief medical officer at the American Foundation for Suicide Prevention. And one of their tracks has to do with medical student and resident physician well-being, but also toolkits that are available. We use them in training a lot about prevention, and also the aftermath of suicide, too. Those are just some of the thoughts I have. But I'm not going to stop there. I'd like to ask either of you to kind of weigh in on that, as well. It sounds like this works. Does this work? Yes, it does. OK. I can say that as a trainee, my favorite patients to work with are those with trauma, and I have not had a recurrence of suicidal thoughts in 10 years, since I started focusing more on my own recovery. I think that while I agree the idea of needing to be recovered for a certain amount of time comes from a place of protection and a place of concern, I do think it also helps contribute to stigma and contributes to the fear of losing your career if you do suffer or if you do happen to have a recurrence. I'm really pretty realistic with myself that I have struggled in the past, and I'm in a high-stress career. I could struggle again in the future, and so keep an active effort to keep an eye on myself and make sure that that's not happening. I think that we need to trust physicians to know themselves and trust physicians to take care of themselves. I think that would help contribute to making space for that to actually happen, because it's hard to take care of yourself and really be honest with yourself if you have a fear of losing your career if something were to go awry. Betsy, is there anything that you'd like to add? I guess I don't think Matthew would have sought help. He was very strong-willed and thought he could fix himself, I think. His primary doctor, actually Matthew did have a primary doctor up in Minneapolis. My mom sees him. Every time my mom sees him, he looks at her and says it's just a punch to the gut thinking about Matt, because he was such a happy guy. Nobody really saw it coming with him, and it happened so fast. I don't think unless he really felt he could confidentially get care that he would have ever helped himself. This is where education does help a lot, because when I was in private practice, I don't know how many physician patients I saw who said, I've been thinking about coming for the last three months, six months, nine months, but I listened to a podcast of a physician, or I read an article written by a medical student or something who spoke openly about their struggle and the treatment they got, and I realized I wasn't alone. That's why I'm here. Not easily, but that's why I'm here. These kinds of narratives and programs like this really serve a wonderful purpose. Yes, please go ahead. Thank you so, so much for sharing your story so openly and honestly and invulnerably. I guess building off of some of the comments that you've made, I think beyond the stigma and the shame, there is the very real fear of professional repercussions, and so often people will not seek help because they then have to explain when they're trying to renew their license why there's this gap. I guess what can we do, or are there ways that we can make it so that these physician health programs aren't seen as punitive, and instead are there to really help and support physicians in seeking help before it gets to that crisis point without that fear? Well, I'm going to start a response to that, and I'm going to actually ask Dr. Muti if she would come to the microphone and pick up perhaps the areas, because both of us have had some experience with this, but I'll start by saying that one of the things that many of us have been working on for some time are working with the Federation of State Medical Boards, in other words, to modernize or update the questions that are asked, that's here in the United States, and at the current time, roughly a dozen states, I think, but this keeps changing, both for the application for the medical license as well as renewal ask no questions at all about the physician's health, none, no questions whatsoever, and New York is one of the states. The states then that are considered okay to ask questions that don't violate the Americans with Disability Act are ones with a question that is something like this, are you currently, and there's three parts to this, are you currently suffering from any illness that could be affecting your ability to practice safe and competent medicine? So what that focuses on is current, so that if you've had something in the past, you don't have to say yes to that question. Suffering from any illness, meaning it doesn't partition off anything psychiatric from a medical or surgical illness, neurologic, and the third thing is it's not asking about just illness in general, it's asking about impairment, which means that impairment means that we are unable to do our medical work because of something affecting our ability to do that, it could be psychiatric, it could be medical, it could be alcohol and other drug use. So and this is a work in progress that increasingly states are changing those questions and they are getting a lot of pressure from many different groups to change those questions. What is a bit slower are the credentialing applications that physicians fill out at medical centers that they apply for, but yet there is something about that that no, this is just anecdotal because I've had physicians contact me, they say look, I got my medical license fine, but then I was asked these draconian questions about my health and functioning by the credentialing committee and I just left them blank and I got the job. Or I just crossed them out and said, this is ridiculous, what are you asking, this is none of your business, I got the job. So I actually called a few of these places, they said, you know, Dr. Myers, thanks for reminding us, we've been going to get rid of those questions for a long time, but we just never got around to it. So I think that that could be more of a sort of housekeeping issue or something, but anyway, we'll see. But Christine, please add. Sure. Well, I wanted to also thank you for this incredible session and Dr. Myers, first of all, your long-standing dedication to physician treatment, mental health, and now suicide prevention, which I know has been a decades-long dedicated interest of yours, as it has been mine. And to each of you who shared your stories, thank you so, so much, and I think that you are joining a chorus of, for those of us who have been in this work for some decades, know that it feels new and scary and highly vulnerable, but I do want to tell you that as somebody who has been out about my own lived experience, which occurred when I was a medical student, and then fast forward maybe 10 years later, fairly young, I became a dean in the medical school at UCSD, and I began sharing the dean for student affairs and medical education, and I got permission to share a brief version of my own story to every entering medical school class and every chance I get. It's really why I stayed in academic medicine for 20 years before I moved over to AFSP nine years ago. So not only have I had the good fortune of being out and joining that community of freedom, really, when you get to live authentically and vulnerably, and I do say that vulnerability can be a superpower, and I understand on the pre side of that, it is so frightening that you can't imagine that it's safe to do so, but having been doing this now publicly for so many years, it can be. And I will say also that over the 10 years I was dean for student affairs, I referred hundreds of medical students, residents, and faculty, colleagues of all different specialties into treatment. I'm a psychiatrist, but as a dean, you don't treat your colleagues and your students, so I was advising and mentoring. And I have to tell you that the fears that we have around medical licensure, which is draconian and archaic, are changing, and that is a huge advocacy movement, and just a plug, it is a state by state decision. So each of you in your states, if you haven't raised your voice, should just write a letter and say this is outdated, look at what the federation of state medical boards has advised all of the state medical boards to do. It is changing. I think it will be a domino effect soon. It hasn't quite reached that tipping point yet. I think we're at about a third of state medical boards that have changed to the appropriate handling of that. So over those years, I had hundreds of them come back and say what had happened after they had gotten treatment, you know, whatever phase of recovery or their situation was, and I think I had one person say that they had remaining concerns about malpractice and life insurance, but not a single person said to me that they had come into any trouble with their privileging committee or their medical board. So I know it can be a real concern. I know there are horror stories that have happened. I think that it is becoming sort of in a way a narrative that we need to counter and actually come out as a community of lived experience to say how we can actually be open and be quite safe about that. So anyway, but I did want to just, I don't want to cut in front of, I'll just make one quick comment. That amongst your physician suicide decedent population, Dr. Myers, that you've interviewed the family members and written your book about, that 15% had not been ever evaluated or in mental health care. On the slightly upstream end of that, at AFSP, we have, we licensed the interactive screening program. It's now in hundreds of workplaces and large health systems for the workforce, and it allows users, us, to, physicians and nurses and other health workers to voluntarily and anonymously engage in this, not only a screening, but to dialogue with a counselor. Again, remaining fully anonymous in your control. You can say I am suicidal and no one is going to track you down because it's not a clinical program. So in that data set of several thousand physicians across several institutions over about a seven year period, the analysis showed that 18% of, again, self-selecting physicians were in some acute stage of currently having suicidal thoughts, 18%, and over 80% of them were in no form of care. So again, I think we have a gap between our knowledge base about mental health being a part of health like every other, and not yet affording ourselves the benefit of addressing it that way. And yes, there are external barriers, but I think we need to encourage one another to really come out and speak, you know, really quite loudly about this. So thank you for publishing and for, again, Dr. Myers, I know you take every opportunity to hold these sessions and continue the fight. So thank you so much. Sorry, I took so much time. Thank you very much. Please go ahead. Yeah. So I echo the gratitude for your narratives and honesty. So I'm a transfer into psychiatry. I actually was a senior surgical resident and left medicine for an extended period, partly because of, hi. Can everybody hear okay? No. Can you guys hear me? Sorry. So I left. I had lived experience. I was penalized for appropriate seeking of treatment. And so I think these are very real and I carry on these concerns when I go for credentialing. It is a welcoming space in psychiatry for which I'm grateful, but not universally so. And I'm in recovery from multiple things. But this year I was on consults and I was called to see a patient overnight and concerned for suicidality, but hadn't disclosed that. After an extensive conversation, found out that this patient was actually a international medical graduate, was a resident who had attempted suicide, had finally reached out to someone and was driven hours to get out of the catchment area of their program. And had been in the hospital over 24 hours without evaluation for suicidality. It was actually someone finally just wondered about the accidental taking of extra Tylenol. And it took about an hour before they disclosed any of this. And I was sitting there and yes, as a resident, as a trainee, as vulnerable, I had been in a similar place and some of those fears were real, but I'm a U.S. citizen. I was a U.S.-trained physician. My status was not at risk. I was able to leave medicine and get other jobs and ultimately come back. But this individual was under no illusion that by seeking care, their visa was at risk. And they weren't sure and I'm not sure. I'm not sure all the protections that exist for U.S. physicians in training, let alone for a population that has very realistic fears about visa status, about shame of having to disclose of decreased access to social supports. I mean, COVID plus being thousands of miles away from social supports, not having some of the cultural resources that they depended on at home. And so I want to ask, what are the resources for some of these more vulnerable populations? I mean, legally we know it's difficult to seek care and there are real concerns. And so I just think in, like, I want to raise up those questions because I think this is a really even more marginalized at-risk population I think also gets taken advantage of extensively in our academic and research communities. I just had a patient deported recently. And so I just want to raise that and ask. Thank you. I really appreciate it. I'm conscious of the time. We just have a couple of more minutes and there's another speaker, but thank you so much for your comment. Please go ahead. Hi, yes. So I had a quick question. I think everybody universally, both in the speakers panel and people who've asked questions have mentioned stigma. And stigma is obviously a big, huge component to what it is that gets in our way, especially as physicians to seek care. But stigma doesn't magically appear one day. And presumably stigma is something that we learn or that we're taught or that we experience. And then it sinks in and then it becomes the thing that gets in the way of getting treatment. Thankfully, medical students and residents are trapped under our control to be taught and fed information. I mean that sarcastically. But we have up to seven plus years to educate the future physicians of America to tell them, look, this is not the way to think about yourself and this is not the way to trap yourself and prevent yourself from getting care that you absolutely need. And maybe self-disclosure is a stigma unto itself. I think the person from ASFP mentioned, it's like coming out. It's in front of a room like this is just one piece. It shouldn't be like that. It should be like, you should just be like another thing. You should be out and proud and it shouldn't be a big deal at all, like any other form of being out. And yet we create that stigma in our field. How can we teach medical students and residents to be anti-stigma? And sir, may I just ask if you have a question or? Yeah. How do we teach medical students and residents to be anti-stigma rather than have a stigma? I think, I think largely by example. But is, but Katie, as you mentioned, I mean there is a downside though to, to some of these things. So let me, let me, I'd like to actually ask both of you to make some comments about that before we stop. Sure. I can make a really quick comment. I know we're short on time. I think a lot of the teaching of that stigma comes through sort of that more like silent or hidden curriculum that people are more actively aware of and are working on dismantling. So I, we learn the stigma by example in clinical situations rather than from lectures. We're not receiving lectures telling us that it's not okay to be, it's not okay to be not okay. It's coming from example. So I think that providing examples to the contrary and pushing examples to the contrary will be the biggest thing that will make a difference. Yeah. I guess I second that. Matthew was a little different in the sense he was very black and white person where I don't really even think he believed in depression until it hit him and he knew it hit him. So I mean as much as I hate to say it, he was probably the doctor on the other side, not really understanding. So I guess it is more of an education thing that we need to talk about and without sharing our stories and talking about it, I don't know how you. I want to, this is a shout out and a salute to you though, because do you remember you, you told me how many people came to Matthew's funeral and yet I presented a situation where hardly anybody from work showed up at the doctor's funeral. And I think that you must have had a sense that Matthew's colleagues or whatever stood up. Well, yes. And like I said, Matt was with a very prominent, large oncology practice in Minneapolis and they actually helped their doctors a lot. They partnered with a group called Vital Work Life in Minneapolis, which I have since partnered with a little bit. I have a little article that they did about my family and they actually helped doctors try to better manage their work life balance, which we felt very fortunate to have when Matt joined the smaller practice in Charlotte, which it was not what he thought it was going to be. I mean, he didn't have any of those resources and I think that's so, so, so crucial for our doctors to be able to have people to reach out to. But Matt did. Matt had a lot of friends and I think his group was more on the forefront of trying to break those barriers and watching out for physician burnout, which as the wife or the bride of a doctor, I didn't even know what that was. I mean, I had no idea. I want to thank both of our speakers and also Dr. Lines, who was here virtually with us today. I want to thank all of you for coming today, for your presence, for your comments, your questions. We have to vacate the room, but we're going to gather out in the hallway a bit. So if anybody has any questions that you'd like to ask any of us, we'll be out there for a few minutes. Thank you. Thank you for coming.

video

speakers

Dr. Michael Myers

Dr. William Lyons

Betsy Gall

moderator

live footage

prerecorded footage

Dr. Termini

mental illness

physician burnout

advocacy work

suicide attempt

support