Out of the Straitjacket. Michael Weinstein Thomas Jefferson University, Michael.Weinstein@Jefferson.Edu

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Department of Surgery Faculty Papers Department of Surgery

3-1-2018 Out of the Straitjacket. Michael Weinstein Thomas Jefferson University, [email protected]

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Recommended Citation Weinstein, Michael, "Out of the Straitjacket." (2018). Department of Surgery Faculty Papers. Paper 154. https://jdc.jefferson.edu/surgeryfp/154

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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 the “nonproprietary naming of biological been averaging 10% per year re- products; draft guidance for industry; avail- cently.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

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-

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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 career 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. But will. They kept me from crossing accompanying self-flagellation. I the burnout had been waxing into the abyss. don’t remember anyone talking and waning for 22 years; now I I had convinced myself that I about such issues back then. was in the worst episode of ma- had end-stage depression, that I was fortunate that my wife jor depression of my life. there were no other treatments,

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and that I would be forever de- back at work in the same capaci- and compassionate group of co- pressed, as I remember my grand- ties as before. I find daily joy in workers. I have learned that father being. Yet my healing has interactions with patients, their many of us suffer in silence, fear- been considerable. I am happier families, colleagues, trainees, and ing the stigma associated with and more optimistic than I have our health care team. I also find mental illness. I feel compelled to ever been in the past 50 years. daily frustration in the workload, share my story, which I’ve found I have never enjoyed being alive the amount of time spent in the offers others an opening to ex- more than I do now, in each hospital, the shrinking control press their own suffering. I be- present moment. we have over our work environ- lieve that by deploying tools for My family, supported by an ments, and the economic drivers reflection and self-care and work- expert-guided, trial-and-error ap- in health care. I am concerned ing together in a brave and disci- proach to pharmacologic thera- for future generations of clini- plined way, we can remove our pies and compassionate cognitive cians unless we change how we restraints and isolation — both behavioral therapy, opened my teach and practice medicine. We figurative and literal.

heart to a new perspective of need to devote time and resources Disclosure forms provided by the author accepting and appreciating life to promoting self-care. Too many are available at NEJM.org. through mindfulness philosophies physicians leave practice prema- and practices. I am discovering turely. Too many physicians take From the Department of Surgery, Sidney the habitual self-destructive pat- their own lives. Kimmel Medical College at Thomas Jeffer- son University, Philadelphia. terns of thought that restrain my I have been open about my ill- unconditional confidence. ness and, though I had feared re- DOI: 10.1056/NEJMp1715418

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