Speaker 1 00:00:15 Today on physicians taking back medicine. Suck it up, buttercup. These two physicians decided that they weren't going to suck it up any longer. Instead, they left clinical medicine to fight to improve the health care system. My name is doctor Maryann Wilber. I stepped back from clinical care two and a half years ago. My journey. It's not really a secret. I was a giant oncologist. I was struggling with getting what I needed to provide good patient care in terms of just support at the hospital and at home. I've never gone into the really dirty details of what was happening because it doesn't really matter. The problems are systemic. They're everywhere, and patients may not know exactly what physicians are experiencing, but they feel it. Patients know that their doctors are distracted, that they're unavailable, that they're busy, that they're engaging with their computers too much, that they're dealing with insurance constraints. They understand that there are frustrations and constraints, but they don't understand how ugly it really is and how handcuffed your doctor is in terms of trying to get you what you need.

Speaker 1 00:01:20 And so I just got to a point where I couldn't look myself in the mirror anymore. I was like, I cannot provide good patient care. And I didn't have the kind of specialty where I could just go out and start my own practice. Gynecologist is a very specific surgeon who does big surgeries, so I need always I need a qualified Pacquiao's. I need ICU blood bank pathology, like really good Gyn pathology. I need chemo nursing, like, you name it. It's part of what we need. And so it's not the kind of thing where I could be anywhere except for basically an employed physician. And that meant I was essentially powerless to decide what my patients received. At some point, I felt like either you're part of the solution or you're part of the problem. At some point, you're complicit in this. And I didn't feel comfortable with that anymore. Doctor Wilber decided to employ research skills that she developed in her public health training to raise awareness about the challenges facing physicians like her. This led to her publishing a book called The Doctor Is No Longer In.

Speaker 1 00:02:32 My two public health series is Qualitative Research. And this is this particular kind of research is done with lots of first person interviews, and then you keep going until you reach thematic saturation. Basically, you keep going until you've heard it all, but you're like, all right, I've heard it all. And then you code it and then you put it all back together, and then you put the individuals quotes back in. It's a very personal kind of research. So I started turning the interviews on. My colleagues at the time, when I walked away, we were expecting 1 in 5 physicians to be looking to get out. By the time the book was published, it was 2 in 5. So I knew what pushed me out, and I knew what pushed my co-author to be looking to get out. And we knew what was pushing our colleagues. And those stories weren't being told. So my co-author and I found physicians all over the US, not trainees, because trainee, that's a whole separate problem and always has been.

Speaker 1 00:03:30 But these are people who are done with training. They are out there practicing. They're licensed in the US, and they have self-identified saying, I'm looking to leave or I have left. And the very last question of this, like very short demographic survey, is, would you be willing to do a 30 minute interview? Everybody said yes. As long as it's anonymous. And we did these interviews. We kept going until we reached thematic saturation, meaning until we were like, yep. We just hearing the same stuff over and over again, now coded it and then turned it into this book. The doctor is no longer in. He went through all those.

Speaker 2 00:04:06 Years of training, all those rigors to be a gynecology oncologist. You have to train for so long and invest so much of yourself, and then you may even have people like, I think there was a legislator recently who said, society pays for doctors to go through all that training, so they do owe us society.

Speaker 1 00:04:27 Yeah. Let's break it down a little bit, because that legislative comment is.

Speaker 2 00:04:33 So.

Speaker 1 00:04:33 Insulting and disrespectful. Okay. One nobody paid. I am still in massive amounts of debt. You know, if we were in almost any other developed country in the world, yes, I would have a debt to society because the government would have helped pay. But that's not the case here. I grew up quite poor, and I care very much about inequality in the US, which is a little bit a part of my story. It also is a part of why I have massive amounts of debt because nobody was able to help. So when I graduated medical school, I graduated with $650,000 in debt. I had applied for special loans for people who are willing to work on, you know, a reservation or in certain underserved. I was absolutely willing to do that. I was not chosen. I actually got to the final round, but I was not offered one of those scholarships. So I went to a private medical school, and I graduated with $650,000 worth of debt. So no, nobody paid for it.

Speaker 1 00:05:38 Let's make that very clear. And that debt lives on.

Speaker 2 00:05:42 Do you make the argument in the book that physicians are core resources of this system, and yet companies are doing their best to not respect or value the work that physicians are doing and therefore driving physicians away. And you say there are studies that show that any system that sacrifices its core resources is inevitably going to collapse. Therefore, the health care system is going to collapse if it continues this way.

Speaker 1 00:06:14 Yeah. At the time when I left 1 in 5, we're leaving. Now it's two and five. And not only are the physicians leaving, doubling physician suicide is also doubling. Those are the two ways that we're losing physicians. And they are both on this massive exponential rise. This is not a coincidence. And trust me, this is not the people who don't care. On the current trajectory, this system will collapse. And at the time that I wrote the book, I was thinking by maybe even ten years. By the time the book came out, I was thinking 3 to 5 years.

Speaker 1 00:06:49 Now, I would argue, honestly, that the system is already collapsing. Maternal mortality is increasing across all demographics, but black maternal mortality has tripled in the last decade. Every sociologist on Earth can tell you when a system was not designed for you. You don't get the right service. We build our healthcare system around the dollar. It's a business in the US. We are the only developed nation that spends almost 20% of our GDP on health care. And what do we get for that quality? Not even close to anywhere in the industrialized world. And so we're we're literally flushing money down the toilet. And where is that going? That is going to the greed. Right? So I'm not fighting against capitalism. The problem is when money is being taken directly away from the patients and anyone trying to care for them. What I really want patients to recognize is that yes, you're suffering. You're fighting with the prior odds for whatever medication you need. You can't get the procedures you need. You're having trouble getting in to see your physician.

Speaker 1 00:08:04 If, God forbid, somebody in your family actually is really, really sick. Medical bills are now the number one cause of personal bankruptcy in the U.S., so patients are suffering. I want people to recognize that the physicians are suffering right next to you. Okay. It's not the physicians that are making this situation. I will say, I do feel like our profession a little bit didn't come to the table at key times about 20 to 30 years ago, when we could have had the opportunity to disrupt. What happened to get us where we are today? But today, trust me, your physicians are essentially powerless in this, like, greater ecosystem of medical care. And they're suffering right next to you now. So what is happening in the US is there are multiple opportunities for greed your insurance company, greed pharmaceuticals, the instruments I used in the O.R., and all of those kinds of things like just massive greed in all of that. And then there is greed at the institutional level. And then we have private equity coming in and buying out physician groups.

Speaker 1 00:09:12 So all these layers are greed and the money is just getting siphoned off. Another big, big change that occurred between 2010 and 2020 was physician employment. We just said, I didn't get into this business for money. I just wanted to care for patients. So if Mr. Businessman wants to take care of the business, that sounds great. But the businessmen feel no obligation to the patient. I shouldn't say no. There is the rare gem, but for the most part, they don't have a sense of responsibility. They have a responsibility to their shareholders, not to the patient.

Speaker 2 00:09:43 I want to share an anecdote that you put in the book that really, to me, is sort of the big picture of the whole problem that we have. You told the story of a neurosurgeon named Guy Clifton, who observed that there were some problems with infections that related back to handwashing issues. So we hear this all the time and what what the headlines will usually say. Doctors are not washing their hands enough. You know, it's always the doctors are bad.

Speaker 1 00:10:11 Yeah.

Speaker 2 00:10:11 So Doctor Clifton said, well, let's do a root cause analysis and see what the problem is. And he discovered there were not enough sinks and stations for proper handwashing. So he went to the administration. He explained the situation. He asked the hospital to please install some more handwashing sinks. And the answer was no.

Speaker 1 00:10:32 My cost money.

Speaker 2 00:10:35 Things similar to this that Doctor Clifton noticed and he kept going to bad. He kept fighting and kept fighting and finally he just reached his limit and he said, I can't do this anymore. He quit. He resigned. And so he left. And of course, the hospital lost a lot of business. And then something that happened that I think was even more important. Was that another physician? Who was going to step into that role, didn't just walk in and say, okay, I'll go along with the hospital. He said, you know what? I'm not going to take this role unless you do all of the things that Doctor Clifton asked you to do to improve patient safety.

Speaker 2 00:11:09 And it was only then that the hospital administration made.

Speaker 1 00:11:13 They tried they tried really hard to not do, but they ultimately needed somebody to take on that role and they couldn't get anybody. It's the doctors who will hold the line. It's the doctors who care about the patients.

Speaker 2 00:11:29 The only reason they gave in or acquiesced to these changes that were in the interest of patient safety were because you put in the book. They were desperate. And this story was so powerful to me because what it said was these were a few individuals not only working by themselves, but with others, but also working together and not having somebody else just saying, well, I'll just step in and do it and just go along with the hospital and make take my paycheck. But having the integrity to stand up and say, I am not willing to sacrifice patient safety. And that was what made the change. Yeah.

Speaker 1 00:12:06 That's sort of the story for all of us trouble makers. Yeah we are. We're labeled as trouble. I am a trouble maker.

Speaker 1 00:12:14 And I'm told that frequently. And I thank you so much for using the word integrity, because it is the integrity to say, no, I'm not doing this anymore. It's not okay. I didn't finish my training till I was 40, 40 years old. I spent my entire 30s and most of my 20s working extremely long hours, putting off childbearing, ruining my marriage, and, you know, going into massive amounts of debt. But I loved it. I loved caring for my patients, and I loved going to the O.R., and I. I dream every night that I'm still operating. A surgeon is who I am. But I just got to a point where my integrity was at risk. And what we call that is the language we use for that these days is moral injury. It's the people who care the most who can't tolerate this. Most of the doctors who are in the system right now and trying desperately to care for you really do care. But they are struggling. And physicians who care a lot are coming out and saying this is not okay.

Speaker 1 00:13:24 I got to a place where I was like, I can't do this any more. And in the research for the book, we tried to figure out what's the difference between the physician who dies by suicide and the physician who walks away and tries to fight because we're all leaving, sort of for the same reason. It's this lack of autonomy to make decisions that are right for our patients, but who dies by suicide and who just finds find that another way to to fight the good fight. And the difference is the investment. So physicians. Being a physician is who we are. It is so key to who we are that a lot of physicians, they can't find their own humanity separate from being a doctor. And if you can't be Doctor Smith anymore and Doctor Smith is who you are. That's when the physician has an existential crisis. And that's when we lose physicians by suicide. It's the ones who care that much that they like. They can't do it because there's this old idea that it's the weak ones.

Speaker 1 00:14:30 It's not. It's the ones who care. That's who we're losing.

Speaker 2 00:14:37 So in the book, you basically give a few kind of optimistic and positive messages that I think our listeners need to know. Number one, you want doctors to know that they are not alone if they are facing this moral injury this day to day struggle, where instead of feeling that you're in a noble calling and following your passion, you're just a commodity or a cog in the wheel. You're not the only one who feels like that, and you're not the problem. The problem is the system.

Speaker 1 00:15:04 One other thing that I found in my research a lot is especially with all that debt. Physicians feel like they can't leave, and so they're trapped in their careers. And a lot of people would refer to it as golden handcuffs. And if you have a spouse and particularly a spouse who's not a physician, they have financial fears and they're linked to you. That person may push you to stay and may not understand how trapped you feel. And that actually can be not a protective factor, but even a risk factor.

Speaker 1 00:15:33 And so I do really recommend that if you think that you're that person who's trapped in your career and could possibly be stuck in and matched where you're having trouble sort of seeing your own humanity and you're feeling the golden handcuffs, and you don't maybe get the support or the understanding that you need with family or friends. Find us. I tell people, go to medicine. It's a grassroots organization. It was started by physicians, but now it's for anybody who just cares about the physician patient relationship. And you will find your people. I don't want you to be alone. That's where I found my community. You know, there was a ton of guilt and shame about leaving clinical care. And that's where I found the strength to to keep fighting the good fight, but in a different way.

Speaker 2 00:16:16 Your conclusion in the book is that we need to make noise to bring about change. We need to let our patients and the public know what is happening. And that's exactly what you've done with your book. And in fact, your book is now being made into a documentary.

Speaker 1 00:16:33 The book is called The Doctors No Longer In. And like we talked about, the interviews were all physician to physician. So it was really to give voice to the physician experience. Both physicians are hardly the only people in this story, right? What about the patients and the nurses and everybody else on the patient care team. What is the opinion of the administrators, the institutional folks, the insurance companies, like let's talk to everybody. And so that's what the documentary is, is to give voice to all of the stakeholders and the audience. This time is a generalized audience. So it's really about making sense of how the hell did we get here and what are we going to do about it?

Speaker 2 00:17:09 The documentary is being produced by another physician, Doctor Todd Orton. Like Mary Ann Wilber, Todd Orton was also impacted by systemic problems in health care.

Speaker 3 00:17:21 My name is Todd and I'm a husband father, a family physician, co-author of a book called Ripple of Change and currently probably best described as a positive disrupter or good troublemaker.

Speaker 3 00:17:32 As one of the executive producers for a documentary in the works called Suck It Up Buttercup Trust and Betrayal in American Medicine. I went through burnout in 2019. That was so painful. I remember hating the job that I had always loved, and it was even hard to describe. And in retrospect it was obvious there was warning signs, etc. I was meeting a lot of obstacles, and then ultimately, when I told my former toxic employer where they could take my job and shove it, I suppose career 2.0 started. I had published my book, and I was in this period of trying to figure out who to connect with and where I wanted to spend my energy, and I started meeting a lot of people through LinkedIn, and Marianne was one of them. She was working on her book, and so we started to become friends. She ran the idea of a documentary by me and what my level of interest would be, not only from a thought leadership perspective, but also a networking perspective, but also the financial component of it.

Speaker 3 00:18:34 And so really, the project started in about October of 2024. And then from there it's been like a thousand miles an hour.

Speaker 2 00:18:42 Todd Otten says that the name Suck It Up, Buttercup comes in part from the mantra that many physicians learn in training, but it was also something that producers of the documentary heard from insurance executives they were interviewing.

Speaker 3 00:18:56 One of the first conversations to an executive was, why are you chewing up your best assets in physicians? And their response was, well, they just need to suck it up, buttercup. And I'm like, okay. Resiliency and effort is not the problem here. There are many things well upstream that are causing these issues, but I think it applies to the patients too. You know, trying to navigate the system for patients at this point is impossible. And so I think that applies to the term replies to really everybody in the healthcare space now and and just trying to get by.

Speaker 2 00:19:30 What is the goal of the documentary?

Speaker 3 00:19:33 Ultimately, what we're really trying to do with this is a few things.

Speaker 3 00:19:36 One, learned helplessness is unfortunately pervasive in the healthcare landscape, not only for physicians, other clinicians, but for patients as well, even administrators. A lot of them are just trying to do their best, and they're trapped in this assembly line, widget making machine that is grinding out dollars. So if we all can realize that our efforts can make a difference, I think that'll be huge ultimately. The second half of the documentary will be about hope, courage and inspiration, really building to an evergreen call to action in the notion of an impact network. There are many amazing organizations around the country. They're trying to do wonderful things, but oftentimes their efforts are siloed and they can't get the synergy or the amplification that they need. If we can successfully create an impact network of healthcare change agents valuing people over profits, the 300 million plus people who are frustrated can get involved in some capacity, and that will be very difficult to ignore.

Speaker 2 00:20:37 I think the title of your book, Ripple of Change, really says everything because it all starts sometimes from one person, one thought.

Speaker 2 00:20:45 One plan of action. And things can just snowball and spiral from there. And I saw in the sizzle reel some of the amazing people that you have participating in the documentary, who, as you mentioned, are all doing really great work. And I love that you're bringing them together. I saw Doctor Wendy Dean, who talks about moral injury. I saw Mark Cuban, who is trying to make big changes in the cost of health care.

Speaker 3 00:21:12 We thought it was very important to have a wide variety of individuals. We didn't want this just to be physicians. So we have nurses. There's going to be the patient voice represented. Some of the other individuals like Drummond, champion of the physician wellbeing space, Camille Burnett, who is a champion for health equity, Wendell Potter, who is a reformed health care executive. Linda Pineau. Tina Shaw how could I forget? Don Berwick. Matthew. Zachary. I believe they call him the the people's voice for patient advocacy. The list goes on and on and on of individuals that we've talked to and had the pleasure of meeting.

Speaker 3 00:21:49 We're at about 70% of our funding we've achieved at this point, which is incredible considering we just started this like six months ago. So that's been going well. But we're always looking for more funding. Every little bit helps. Five bucks, ten bucks. Of course, if you want to send in more, that's amazing too. In terms of when we think the project will be completely done, we are obviously building the airplane as we were flying it. But in talking to the creative part of the team, we think that November is very realistic for a finished product. And if you think about it from our first interview with Wendy Dean, which was in November of 2024, to a finished feature length documentary 12 months later, I think it speaks to the energy and the effort behind it. Our ultimate goal for this project is to get it on a streaming service, and I think by doing that, we hope to get this in front of millions of eyeballs in the United States, because we need those patient voices with us to really facilitate massive systemic change.

Speaker 2 00:22:52 And is that the ultimate goal of the project?

Speaker 3 00:22:56 Oh, yeah. We don't see this as having one defined call to action. We see this as a way to connect all these amazing individuals that are out there, so that there can be a call to action after a call to action, because there is so much work to unwind the legacy institutional things that are going on that are well funded, well lobbied, and have a lot of power, that are very happy making a lot of money and keeping the status quo as is. Unfortunately, clinicians, physicians and patients are getting buried in the process and and honestly, at times killed over for the sake of profits. Some of the stories I've heard, Rebecca, it's something out of a horror story or a movie gone really bad. And at the end, someone dies as a result. And that's not even getting into the conversation about the suicide rates and physicians and other clinicians. It's scary. There isn't going to be anybody left to care for people if we keep going like this.

Speaker 3 00:23:53 We need to start thinking longitudinally and not just the short term ROI. A perfect example is when I left my former practice. The big driver behind the scenes was to move me from an office that was absolutely thriving. But ultimately the decision was to save money on rent, and they were going to move me back to the town where I had experienced burnout. And I don't think people really realize how much trauma you endure when that happens. It's a lot. I mean, even walking into certain buildings brought back horrible memories, and that is not putting someone in a position to do their best. It was the following day when I resigned because a decision over saving X amount of dollars led to me tipping over a domino, just to put it in concrete numbers the day that happened. There were 15 of us working at that clinic, four clinicians and the nine support staff. Fast forward four months later when my tenure ended. Nine of those 15 left that hospital system, including three clinicians. You tell me how much money that decision to save money on rent cost that system a factor of at least ten.

Speaker 3 00:25:06 So we need to think differently. We need to do things differently. And that's really what we're trying to accomplish with the documentary. You know, we've been talking a lot about connection. And I think particularly as physicians, we were taught, at least when I was taught to quote unquote, suck it up, buttercup. So we never really reached out for help. I think we need to be looking out for each other better than we have done historically. Asking a colleague if they are okay could literally save someone's life. And the other thing that I'd like to mention is to talk about the power of one plus one. One plus one in my mind, can be infinite. potential. I think about my relationship with Joshua, Judy, my co-author, and our work together. One person plus one person at this point has touched thousands of people's lives. And it's those interactions you have. Sometimes you have to chance. You have to stand up for yourself or your colleague, and that can make all the difference in the world.

Speaker 2 00:26:01 Thanks so much for listening. To physicians taking back medicine. A new podcast sponsored by Medical Economics. I'm your host, Doctor Rebecca Bernard, bringing you stories of day to day physicians just like you, who are fighting to improve the health care system. Thanks for listening, and we'll see you on the next episode.