“Aunty blew her brains out a few weeks ago!” Words I shall never forget.
For weeks, she had been in my thoughts. But I never called her. I didn’t because of all the myriad reasons we often give ourselves for not checking up on each other.
In my case, they sounded like this; “I am 7 months pregnant, and it has been a difficult pregnancy.” “I am in an abusive marriage.” “My pediatric practice is struggling.” “I have a 2-year-old son,” and so forth. When I eventually dialed her number, her niece told me she had killed herself. She was only 33 years old. A surgical resident. My friend and colleague. The news of her death sent me into preterm labor with my now 20-year-old son.
Physicians should be brilliant, resilient, and darned near perfect. We cannot afford to make mistakes (no pressure).
We must show up 100% each day with our game faces on, with a smile, ready to serve and save lives!
We must never tire; we must love our jobs and not give-in to overwhelm or toxicity at the workplace.
We must thrive regardless of near inhumane working conditions. But what if we can’t? What if we are actually human? What if the rest of the world sees us as one of them? What if we see ourselves as human and as such fatigable, maybe even fallible?
What if we save our patients but not ourselves? What if “first do no harm” protects everyone else but us? What if our beloved profession becomes a noose around our necks?
What if we are unable to cope with life during a pandemic; family, relationships, money, illness, colleagues, workplace abuse to name a few? What if we find themselves hopeless, helpless, and trapped in our “perfectionism”? What if we pay the ultimate price for all this with our lives?
Does anyone notice? Are we missed? Is anyone counting?
Globally, physician suicides are at an all-time high. And female physicians have a higher mortality rate by suicide than male physicians in the United States…and like most suicides, it is grossly under-reported.
I know, I am a female physician in the United States, and I have been suicidal.
More women are entering medicine than they were before 1980, but women in medicine still face a wage gap, a risk of sexual harassment, motherhood, relationship issues, and other disparities that can contribute to mental health challenges and suicide.
This burden is worsened by fears of being seen as less capable, an educational system that stresses care for others over care for self, and licensing and credentialing requirements that often punish physicians who accurately report their diagnoses and treatments.
Results of a systematic literature review and meta-analysis show women physicians are 46% more likely than their female counterparts in the general population to die by their own hands. Sadly, the Covid-19 pandemic has worsened physician moral injury, burnout and suicide.
It has exposed the inefficiencies in healthcare systems across the world, particularly in the United States, and exacerbated the toxic stress physicians have been experiencing for a while now. To my knowledge, there has been one reported physician suicide each weekend for the last 4 weeks in the United States.
And no one is really talking about it.
However, what is our role in preventing our own suicides? According to Dr. Ann McCormack’s article in the Medical Journal of Australia, “Among the medical workforce, work–life balance is poorly practiced and modelled.” “In fact, there is a subtle undertone rampant within the medical fraternity, in which late-night emails, missing a child’s school concert, publishing multiple articles a year, and not taking annual leave become unvoiced indicators of a truly committed doctor.”
No truer words, if we be honest with ourselves…
Thankfully, there is hope;
1/ According to the American Medical Association (AMA), Physicians can seek help, and not be “punished” in most states of the U.S.
2/ Healthcare institutions can put processes in place for physician wellness and ensure physician adherence.
3/ Doctors themselves should invest in activities that will build resiliency and support their physical and mental health, and model such behaviors to their colleagues.
3/ Physicians should be encouraged to be each other’s keepers through kindness, and practice empathy and compassion towards one another.
4/ The general population should be educated to end the silence, shame, and stigma associated with the word “suicide”.
5/ We should normalize discussions around emotional trauma and mental health challenges and avoid any repercussions towards doctors who speak up and speak out.
6/ Medical students should be selected based on both academic performance and aptitude tests, and regular enquiry into, and support of their mental health should be a high priority.
I am sitting in my home office on a sunny Thursday afternoon, as I write this letter to you.
In the past year since I quit my full-time job as a pediatrician to start speaking on child, teen and young adult depression and suicide, (read about it here and here). I have discovered a different side of me. The side that loves to write, and speak. The side that is an activist for a cause. The side that was lying dormant until the passion to actively save the lives of children and teens through creating awareness was ignited when my then 7-year-old patient attempted to hang himself in May of 2018.
I have always known that medicine, pediatrics, in particular, is my life, and public speaking is second nature, so it was sort of a natural progression for me. I have never had any trouble speaking in public to air my opinion, so when this opportunity to practice medicine in the most preventative way picked me, I had no hesitation to say, a resounding…yes! As the good book says, “many are called, but only a few are chosen”.
Though I don’t know when it will get published, I couldn’t think of a better day to write this letter than today, the 12th day of September, two days after September 10, which is recognized as World Suicide Prevention Day. This week marks National Suicide Prevention Week 9/8 to 9/14. A week which eerily includes September 11, a day suicide bombers set our country on a never to be forgotten path, a day that will forever go down in infamy, in the month of September, suicide awareness and prevention month.
This letter is, however, not about suicide days and suicide bombers. It is about a path that has led me, a Nigerian-born mother of three, a board-certified pediatrician, to become a speaker, bestselling author, and activist on youth suicide. It is about how finding a new way to practice medicine is allowing me further my cause. Every time I tell people what I speak about, it never fails, they look up, and suddenly get interested, no matter what they were doing before I started speaking. Some look at me with concern, some look at me with disbelief, and yet some look at me with sorrow, especially when I tell them my story, my why, which you can read here. Usually, by the time I am done, a majority of my audience wants to know where they can find me, where I practice.
For the past year, my response to that line of questioning has been a combination of the following…” nowhere in particular”, “I don’t have a practice”, or “I quit medicine to speak publicly”. To which even more eyes look at me with a mix of wonder, pride, gratitude and amazement… and then after a brief thought, pretty much everyone says a combination of “that’s such an important topic” or “that’s so needed” or “wow, thank you for the work you are doing”, etc.
As I have continued to speak locally, around the country and internationally, and as the questions have continued to come in, I have had to finally admit to myself that I have missed practicing medicine. I have missed clinical practice, but most of all, I have missed having physical contact with my patients. Those who know me, know my patients are my “anti-kryptonite” (if that is a word). That been said, I have known in my heart that I did not want to go back to traditional medicine (what I call “assembly line” medicine). The kind that is run by CEOs with little or no knowledge of what it’s like to have boots on the ground. The kind that has enslaved us doctors and caused burnout to now become a household phrase. The kind that puts profit and the bottom line before patients and providers. The kind that you, me, we, did not sign up for. The kind we did not dream about in our days in medical school. The kind that has unfortunately driven too many of us (400 per year at last check) to early deaths through suicide.
I knew that kind of medical practice was definitely no longer for me. So, I tried out Locums, but with my son still being in grade school, I am unable to travel out of town as much as most locum gigs would require, plus, I am only licensed in Texas so that limits me as well. I know the hospitalist route is not for me. So, while I was still pondering my next move, I happened upon a facebook group called DPC Docs. A two-thousand strong community of doctors practicing medicine on their own terms. I had actually heard of DPC about 2 years ago. Direct Primary Care. Three words that are turning out to be life-changing for those of us who care to look closer, look further and farther, think outside the box, and dare to be bold enough to say “enough already” to the big bosses and take back our lives.
I happily jumped in with two feet. You see, Direct Primary Care is exactly what Dr. Universe ordered for me. A spin-off of Concierge Medicine, DPC seeks to allow doctors to practice medicine the way it was meant to be. I had heard about it through a podcast that featured one of the true pioneers in DPC practice Dr. Josh Umbehr of Atlas MD in Wichita, Kansas. I remember excitedly running to find my spouse to tell her all about it that evening. I was so intrigued by the model, I was immediately hooked. And even though I knew the traditional medicine model I was in as an employee at that time was toxic for me, it still took me nearly 2 years to act on it. Not because the process is hard, but because I needed the right mindset and star alignment to get over the voice in my head telling me to stay put.
As soon as I decided to start back clinical practice, I knew it had to be on my own terms. My first order of business was to call the Texas Medical Board and enquire about my idea to only attend to at-risk youth aged 8 years to 18 years who are the exact population that I speak and write about. When the lady on the telephone told me I could, that was one of the happiest days of my life! Her words were something like “ma’am, as long as you are licensed to practice in this state, you can see only those born on the 5th of May if you like”. That essentially spun off my dream to open my own youth health center that would cater to the children that had picked me those many moons ago!
Do you know that it took me less than 6 weeks and cost me less than $10,000 to set up? I have a micro DPC practice model, that means I have no front or back office, no fancy equipment, no staff, and an expected patient panel of less than 300, compared to nearly 2000 which I had at my last place of employment. The way my practice is set up, I shall see only 6-8 patients a day for up to 1hour or more per visit, three days a week, compared to 35-45 patients at my last multigroup practice employment. My monthly overhead is far less than I had when I owned a traditional practice, my EHR is user-friendly and convenient, my stress level is low, my patients are happy, and so am I 🙂
While this might not work for many, it works for me and others with a small niche. My friend, Dr. Amber Price of Willow Pediatrics up in Chicago, Illinois’s niche is only newborns. She incorporates home visits as part of her practice. Yet another friend, Dr. Sara Sultz of the DOC group up in College Station, Texas does home visits as well as telemedicine as part of her pediatric DPC practice. She even gives vaccines and IVF right there in the patient’s home! Such is the new way to practice medicine, and I am proud to be a part of it, and to announce that I am the first and only pediatrician in Texas and the US with my specific niche in this particular model.
So, what exactly is DPC? And why is #yourstruly so elated about it? Ironically, many of the doctors that I speak with have never heard about it. A few have heard about concierge medicine, but not many, much like I was a few short years ago.
In the Direct Primary Care practice model, the emphasis is on affordable care. In its purest form, no insurance or third-party payer is accepted. That right there puts the first nail in the burnout coffin! I was like “whaaat?” No insurance means; I. Get. To. See. My. Patients. For. As. Long. As. I. Want. To! Yassss!! We do encourage patients to keep their health insurance, and some practices will even generate invoices that might be reimbursed by the patient’s insurance after each visit. The model is based on a flat monthly fee in exchange for services, longer times spent with the patient, more intimate doctor-patient relationship, overall lower healthcare costs, direct access to patients both virtually and in person, improved work-life balance for physicians; thus drastically reducing burnout, reduced patient load, and reduced administrative costs and overhead burdens. The increased intimacy with patients is a huge win for me, especially with the niche I see. Like any business, the fees vary depending on location and market competition.
The key here is; it is a membership model, much like Netflix or your gym membership. My patients have access to my cell phone number to call, text, email or facetime me whenever they need to, and they can be seen, as many times as they like to, each month! My question to you is; when was the last time you had that kind of access to your doctor? Let’s take for instance a 14 year old who is experiencing a depressive crisis at 2pm in the afternoon while at school, they would have the ability to call or text me right away, and not have to wait until they get home, inform their parent, who calls the next day only to get an appointment for the next week, take time off from work and school to arrive at the appointment, only to wait for one hour in the waiting room, and the doctor spends all of 10 minutes seeing them. Then wait another 2-3 months to get an appointment with the psychiatrist who may or may not accept their insurance, or is very likely to charge them 2 or 3 times my monthly fee for only one visit! Get it? #aintnobodygottimefordat!
Some DPC doctors are set up like traditional practices with office staff, laboratories, X-ray equipment, EKGs, and whatever else they need. Depending on state laws some also dispense medication in their practices, (Texas aint one of them…:) all for the same flat monthly fee. It’s just like a gym membership or Netflix for your doctor! In my case, for less than a cup of coffee at #Starbuxx my patients can see me everyday. Oh, and they don’t need to live in San Antonio Texas, I also have telemedicine included in the practice, so I can consult with patients virtually. Other services I am so proud we offer are a teen-2-teen support group (because teens speak teen, they don’t speak adult) and parent coaching, both of which I facilitate.
For now, I am loving DPC. It affords me time in my week to “mother” my children the way I want, be an awesome spouse to my Beloved, make time in the week to blog, work on my speaking gigs, record and edit my podcast; Suicide Pages with Dr. Lulu, The Podcast, you can subscribe, download and listen to it here and everywhere you listen to podcasts. I am finishing up my second book, a chronicle about Teen Life (my first book; a Parenting Guide, can be bought here). I have many more tricks up my sleeves in the coming weeks, so #staytuned.
In conclusion, I believe I have found my happy place in medicine again. While DPC might not be for everyone, it is for me, and it might be for you too, think about it. You never know. Here’s what you do, first start by conquering, silencing or banishing that voice telling you you can’t do it, the rest will fall in place. Ultimately, Happy Patient: Happy Doctor is what we all seek, right? Keeping it simple is what our mom’s taught us, yes?
So, I ask this time, dear doctor, will you DPC?
“We can’t be afraid of change. You may feel very secure in the pond that you are in, but if you never venture out of it, you will never know that there is such a thing as the sea, or an ocean. Holding onto something that is good for you now, may be the very reason why you don’t have something that is better.”
― C. JoyBell C.