Thomas Jefferson University Jefferson Digital Commons Department of Surgery Faculty Papers Department of Surgery 3-1-2018 Out of the Straitjacket. Michael Weinstein Thomas Jefferson University, [email protected] Let us know how access to this document benefits ouy Follow this and additional works at: https://jdc.jefferson.edu/surgeryfp Part of the Mental and Social Health Commons, and the Surgery Commons Recommended Citation Weinstein, Michael, "Out of the Straitjacket." (2018). Department of Surgery Faculty Papers. Paper 154. https://jdc.jefferson.edu/surgeryfp/154 This Article is brought to you for free and open access by the Jefferson Digital Commons. The effeJ rson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The ommonC s is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The effeJ rson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Surgery Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: [email protected]. PERSPECTIVE Friction in the Path to Use of Biosimilar Drugs 2016, and growth in spending has From the Department of Health Care Policy, comments on its guidance for industry on Harvard Medical School, Boston. the “nonproprietary naming of biological been averaging 10% per year re- products; draft guidance for industry; avail- cently. Thus, competition creates 1 . IQVIA Institute for Human Data Science. ability.” October 27, 2015. the potential for considerable sav- Medicines use and spending in the U.S.: a re- 4 . Baumgärtel C. Australian medicines view of 2016 and outlook to 2021. May 2017. authority positive towards biosimilar inter- ings — but if the impediments 2 . Cohen H, Beydoun D, Chien D, et al. changeability. GaBi J 2017; 6: 41. continue, important savings will Awareness, knowledge and perceptions of 5 . Price WN II, Rai AK. Manufacturing probably be left on the table. biosimilars among specialty physicians. Adv barriers to biologics competition and inno- Ther 2017; 33: 2160-72. vation. Iowa Law Rev 2016; 101: 1023-63. Disclosure forms provided by the author 3 . Federal Trade Commission Staff. Com- DOI: 10.1056/NEJMp1714908 are available at NEJM.org. ment to the FDA in response to a request for CopyrightFriction in the Path to Use of Biosimilar Drugs © 2018 Massachusetts Medical Society. Out of the Straitjacket Out of the Straitjacket Michael S. Weinstein, M.D., M.B.E. see him, maybe not so clearly. differently from some of his edu- ternating with 48 hours off, to I He is in isolation, in a strait- cators and emulate the many maximize the consecutive hours jacket. He’s just been committed, who inspired him. we could spend with family or given a shot of haloperidol after I know all these intimate de- friends. They call it “residency” he resisted going to the locked tails because I am this surgeon- for a reason, we were told. ward. He kicked, screamed, patient. I became an acute care sur- yelled, threatened . and geon, commonly known as a now he cries. trauma surgeon. We are the In the middle of elective ones who respond on a mo- inpatient electroconvulsive ment’s notice to care for the therapy for treatment-resis- seriously injured. We remove tant depression, he had be- unwanted appendices as well come profoundly depressed, as desired limbs. I remem- delirious, and hopeless. He’d ber the pain, early in resi- lost faith in treatment and dency, of witnessing a young in reasons to live. He with- man who had lost both his drew to bed and would not arms in an electrical inci- get up or eat. He had to be dent, but my recollection of committed for his own safe- the countless limbs I subse- ty. Several security guards quently removed is vague or had to forcefully remove him nonexistent. from his bed. We attend to critical ill- He happened to be a 48- ness and have tools that save year-old surgeon who worked people’s lives, but sometimes in an academic medical cen- I know I have used them to ter. He had gone to medical My training occurred before extend life too long. We face and school intending to become a work-hour regulations were creat- witness death on a daily basis. family doctor like his father. He ed. Every-third-night call was the We care tremendously about the never imagined becoming a sur- norm; every-other-night was com- welfare of our patients, their geon; he thought surgeons were mon. On one rotation, we were families, our trainees, our col- pompous, and that’s being kind. “rewarded” with being the opera- leagues and coworkers, though I But he fell in love with surgery tive resident on post-call days, haven’t always shown that care — the decisiveness, the immedi- which extended our shift to near- as well as I could. We often make ate “cure,” the bravado. He prom- ly 36 hours. On my trauma rota- decisions in the face of uncer- ised himself he would behave tion, we took 48-hour shifts al- tainty that deeply affect our pa- n engl j med 378;9 nejm.org March 1, 2018 793 The New England Journal of Medicine Downloaded from nejm.org at THOMAS JEFFERSON UNIVERSITY on March 20, 2018. For personal use only. No other uses without permission. Copyright © 2018 Massachusetts Medical Society. All rights reserved. PERSPECTIVE Out of the Straitjacket tients’ lives. When things went knew how to listen and under- I wanted out, out of work and wrong, I frequently blamed my- stood my world. I endured. I com- out of life. I wished I would get self. I learned that doubt, igno- pleted residency and fellowship hit by a car, and sometimes took rance, and lack of confidence and continued to endure for 16 steps to increase my risk. I felt were my own failings. years. Outside observers might trapped in my work and worried As attending staff, I still take have perceived me as “having it that I would expose my short- 24- to 36-hour “shifts” of in-house all”: a surgeon with leadership comings if I sought a leave or call. A third to half of my week- promise, with an amazing wife disclosed my feelings. I’ve sub- ends may be spent in the hospi- and two great kids, who’s paid sequently learned that my col- tal. Early in my career, I even more than I ever expected to earn. leagues were quite concerned covered full weekends in the hos- But enduring is not thriving. about me but found me unrecep- pital, a 72-hour shift, in order to I had heard of burnout but didn’t tive to attempts to help. I was have more whole weekends with really comprehend it. And though trying to get help in many ways, my family — and probably to I had mental illness, I still saw but nothing seemed to work. demonstrate my machismo. it as a weakness, a personal fault. My functioning continued to One might have predicted my I remember early in my career decline until I could barely inter- act with others. My wife forced me to see my family doctor, who My work lost meaning; I was just going insisted I take a medical leave. through the motions. I thought everything I went electively to a psychiatric hospital. It was humiliating. I was I tried to accomplish was a failure. scared, and I was certain my ca- reer was over. I had trouble relating to patients I went through a full course and felt the urge to avoid encounters of electroconvulsive therapy and other treatments and felt better altogether. I cared less and less for a while. I even returned to work, prematurely. My depression about anything I was doing. came back with a vengeance. My severe psychological pain was fall. I have had depression and hearing of a colleague who took unrelenting. I was suicidal and dysthymia since my teen years. a leave of absence for a “nervous developing a plan to take all the When I was a third-year resident breakdown.” I joked about it, said pills I had. Even as I held onto with increasing operative inde- he was weak. Now it was my turn. the love of my children and wife, pendence, a couple of surgical My work lost meaning; I was my brain told me they would be complications threw me into a just going through the motions. better off without me. I contem- funk. I convinced myself that I I thought everything I tried to plated death, though I feared the shouldn’t be a surgeon. I wasn’t accomplish was a failure. I had finality — perhaps death would good enough, technically or cog- trouble relating to patients and be even worse than what I was nitively. I didn’t have the forti- felt the urge to avoid encounters experiencing. tude. I was a fake. altogether. I cared less and less You would not be reading this I didn’t know what to do with about anything I was doing. I today were it not for the love of these feelings. I didn’t believe didn’t know it then, but I had my wife, my children, my mother anyone around me had similar long experienced classic signs of and sister, and so many others, thoughts. I didn’t know how to burnout: emotional exhaustion, including the guards and doctors talk to my coresidents or faculty depersonalization, and low per- who “locked me up” against my about medical mistakes and the ceived personal achievement.