Interview with Dr. Elizabeth Poorman, Internist at Cambridge Medical [Show Summary]
There’s a lot of talk (and only that) about burnout and depression among medical students, residents, and physicians, but Dr. Elisabeth Poorman is attempting to do something about it. Listen in to today’s episode and understand a bit more about the realities of working in a field where you can’t always save your patient from suffering, and how important it is as a doctor to take care of yourself first, so you can then effectively take care of others.
Taboo No More: Depression & Burnout in the Medical Field [Show Notes]
Our guest today, Dr. Elisabeth Poorman, is an internist at Cambridge Medical. She grew up in Chicago, attended medical school at Emory, and did her internal medicine training at Cambridge Health Alliance where she now works in Everett, Massachusetts. Her primary patient population is immigrants and those dealing with addiction. In her spare time, she also writes, movingly and well about the challenges facing physicians and physicians in training. Her writing has appeared in Doximity, Kevin MD, and other sites on the web.
Can you tell us about your background? Where you grew up? What do you like to do for fun? [1:57]
I was one of those weird kids who always knew she would be a physician. I loved to rush to people who were injured, take care of them, was always fascinated by the human body, and being a doctor was always something I wanted to do. I will admit I did feel less sure for a brief period in college. Much of the path to medical school has nothing to do with medicine. I was taking chemistry, organic chemistry, physics, etc., and I enjoyed the contents of the courses, but they more served the purpose of weeding people out of medicine as opposed to opening up your mind to the possibilities. I was looking at the people around me who seemed very sure of their path and didn’t feel like I fit in with them. The ironic thing is that most of them ended up going into investment banking anyways. In retrospect they were very high achieving students who saw medicine as a good financial decision at the time but then made a different choice to make more money and ended up washing out of medicine. After a little bit of working after college, with non-profits and doing international work, I realized I really did want to pursue this path so I found my way back.
Can you talk a little bit more about your project in Brazil? [4:43]
I did my undergrad thesis on leprosy in Brazil. I was so fascinated with it, and continue to be with the ways patients were treated and mistreated. The experience has repeated itself in different countries in different ways. Patients have been separated from their families, experimented on, had their children taken away. I was incredibly lucky to spend so much time living in the colonies, seeing many who have been cured of it but with long-lasting effects. I am fascinated with the ways science and medicine were manipulated for political reasons. Leprosy is not a very contagious disease, actually, and being in close contact isn’t necessarily going to give you leprosy – no one who worked in the colonies got it. By creating these colonies it was an easy way to say they were doing something about the problem but also having full dominion over patients to experiment on them. It is a really dark chapter in medical history, but what was heartening was that people I worked with didn’t tell me not to go to medical school. They said, “Remember our experience and how wrong things can go, and be a doctor because it’s in your heart, not just your profession.”
How long was the gap for you between graduation and medical school? [9:03]
It was a two year gap. I worked on the leprosy project and one at Harvard Medical School studying cultural competency in medicine.
What did you like best about your medical school experience at Emory? [9:26]
I was lucky enough to work a lot at Grady, a very large public hospital that like all public hospitals has the mission of serving everyone regardless of who they are. Because the need is so great in a hospital like that, there are a lot of opportunities for medical students to advocate for patients, and expand support that the team is offering. I was really lucky in that way. If you are working with a wealthier population there is more observing and not seeing the extremes of poverty you see in a large county hospital.
How did you decide to focus on Internal Medicine? Addiction? [10:34]
I decided on Internal Medicine because I wanted something that was really broadly focused on the pathological basis of disease. It deeply satisfied the nerd inside of me! With addiction I am responding to the great scourge of our time – what is killing my patients oftentimes is addiction. For me it’s been mostly on the job training working with people, though my history of science background is quite helpful. You talk about paradigm shifts, and there is no better example of this than the opioid crisis. Initially it was thought continuing to prescribe painkillers was the right way to go, but now there is so much death and suffering you need to think about where this idea came from to keep prescribing, and whether or not we are practicing sound medicine.
Are you happy you made the professional choice you did? [14:00]
Yes. We are at a really unique time period that I am still trying to wrap my head around. What is the way forward? I consider the American healthcare system to be deeply immoral, promoting suffering in search of profit. Unfortunately medicine has traditionally been incredibly conservative and we’ve been taught to keep politics out of the exam room and not engage with advocacy, but then we end up aiding and abetting a system that doesn’t treat people in a humane fashion and continues to get worse for both patients and providers. The short answer is yes, I am happy with my choice, but the longer answer is yes, but now what? How do I use my training and outrage and sense of injustice on behalf of my patients and colleagues?
Was there ever a time either in either medical school or since when you really wondered if you had made a mistake and thought about leaving medicine? [15:31]
I had a very severe episode of depression my intern year which I’ve written a lot about. At the time it felt like a very individual experience. Everyone around me seemed to be thriving and doing so well. I was failing, taking longer to take notes, overwhelmed by patient suffering, and feeling like I didn’t measure up. I was so lucky to have people that supported me, particularly people who were further along in the program than me who told me they had experienced depression as well, it’s not an uncommon thing, and said they got better and I’d get better, too. The really terrible thing about depression is you lose perspective and insight, so I am forever grateful to those people who were vulnerable with me. Once I got better I was very vocal about it based on some very public suicides during my intern year. Unfortunately they were not the last. Then people started coming to me to ask for advice. It kind of shows how few people are willing to talk about this. When I started digging into it, depression is actually so common as to almost be a rite of passage.
Why is it that medical school students seem to completely miss depression in themselves? Do you have any theories on that? [18:43]
I think stigma is the most important thing. Depression in physicians is seen as a sign of weakness, and is associated with the larger stigma of mental health in society. There is a larger cultural issue such that we like to think of ourselves as being hero physicians during premed courses in college. I was intimidated by people who stayed up all night to memorize facts to get a good grade. I thought maybe I didn’t have what it takes. Any sign of vulnerability is a sign that you might not make it.
Then ultimately you are faced with a problem that is unsolvable. We are all going to die. There is a certain amount of that process which is necessarily heartbreaking. Honestly, if you are not depressed at some point in your training you aren’t paying attention. As I mentioned, a system that treats people deeply unequally – to be at the crux of that yet not given an opportunity to advocate for a better system – is deeply disturbing. There is also so much fear that in acknowledging you could be suffering from depression you could be punished for it. I feel very stuck because there are a lot of advocates that don’t want to discuss this. You need to disclose any kind of mental health treatment (as if it’s a bad thing) which is so bizarre to me. What they should be saying is, “If you haven’t had mental health treatment you’re probably in trouble, and here is where you should go.” Medical students will rationalize away what they are feeling and continue through their career. I can’t tell you how many times I’ve been cornered at an event by an older physician who says, “Maybe you aren’t as resilient as we were.” I can guarantee that by the end of that conversation that same physician will be saying, “Wow I guess I was really depressed in training, too.”
Do you think that the problem of physician depression has increased or is that just a perception, perhaps due to more reporting of depression? [23:31]
I think there is certainly more discussion, but I also think it is getting worse. I think it is getting worse because the complexity of medicine is increasing at an exponential rate, but we are still training like it is the 1950s. We are asking people to memorize things on notecards and use systems and ways of thinking through problems that don’t apply anymore. On top of that the productivity requirement and simultaneous dysfunction are spiraling out of control with no end in sight. I find the work rule to be a very disingenuous response to a real crisis. 80 hours a week is unreasonable – then you have to go home and study! Programs did complicated redesigns with people doing more overnight shifts, and with certain parts of hospital having less staff. Residents are doing way too much work, more and more paperwork, and there is more stuff to know. The conversation has been stuck on work hours, which should be a done deal. It’s not safe, and is not dealing with the problem. It is also driving a wedge between generations, with the older generations saying, “I went through it, and so can you,” not, “Is this the best way to make a physician?”
Several of your articles deal with the issues of burnout and depression among physicians. You distinguish between the two. What’s the difference? [27:42]
I’ll say first of all I don’t like the term “burnout” since it’s not particularly clear what the definition is. The larger issue with the term burnout is that researchers mean one thing and the public hears something different. Researchers mean compassion fatigue – so the sicker, poorer, needier the population you work with the more likely you are to experience it, as there is a limit to what human beings can process. For the public burnout means my physician doesn’t care. I tend to avoid the term and instead focus on depression because 1) It is incredibly under-recognized, and 2) I’ve had several physicians say to me they are burned out and me say, “No, you are suffering from depression and need treatment.” I think people use burnout as a euphemism for their own condition which prevents them from getting necessary and effective care.
You recently wrote “Congrats, Med School Grad! Now It’s Time To Find A Therapist.” Do you make that recommendation for all med school grads? [30:53]
Absolutely. For the fundamental reason I said before: death always wins. Even if you are supported, have adequate sleep, and eat healthy, there are still days you will have a lot of difficulty with the terrible things that happen to your patients and things you are unable to stop. As a performance issue, to stay healthy enough to treat patients the way they deserve to be treated, everybody needs a therapist. We have incredibly high rates of suicide in our profession and it is very difficult to navigate and find a system and provider when you are already feeling terrible. Not everyone is ready to do that. For me everything came to a head, and once I named my own depression, because of my training I recognized it’s a medical problem and that with treatment I am going to get better.
What do you think medical schools and residency programs should do to reduce the incidence of physician depression? [33:57]
There are so few advocacy organizations willing to speak openly about physician suicide, instead always wanting to label it burnout. I say to any organization working with physicians concerned with issues of burnout that they need to have comprehensive mental healthcare support in place. We see our colleagues suffering and they try to seek care and are treated in ways that stigmatize them and make their situation worse, which discourages everyone else from seeking care. I work with a psychiatrist who said when he treats physicians in his practice on average they have been suffering for seven years, so there is definitely a lot of intervention that can be done on that side. A lot of people become depressed because our work conditions continue to deteriorate, and I don’t see a lot of solutions on the other side. One committee for interns and residents has done some really effective interventions at different programs focused on decreasing administrative burden for residents so they can spend more time with patients. Individually I look for ways to do that. When I look at a screen I don’t feel as engaged with the patient, so instead I bring a notebook and pen. We make an agenda together, I take notes, and then I go hide wherever I can to get the info on the screen, but I am not willing to go home to 6-7 hours of charting. It is tough to figure all that out, and I am amazed we have allowed a system to be created this way to make it impossible for us to do our jobs.
How do you see your career evolving now that you are a practicing physician? [44:08]
I want to keep working with physicians, physician assistants, nurses, and other healthcare workers to create a system where you feel you can advocate for your patients. I try to do that on an individual level. In the larger sense, continue writing about what we experience and in the future maybe doing more research.
What would you have liked me to ask you? [45:10]
If people are listening and wondering what to do about this, feeling like you’re suffering and need help or it may become an issue, I would first reach out to your colleagues and ask them about their experiences because support systems are highly local. A lot of people will have experienced what you’re experiencing. Not everybody will respond positively, but a lot of people will be really grateful for your openness and vulnerability. I would also encourage people to look for mental health providers outside of their system, as it gets rid of the fear of confidentiality and also is nice to get away.
If you are going into medical school and all of what we’ve talked about today seems overwhelming, what I would say is you have to remember you are your most important patient. Your health and wellbeing has to be number one always. If you can’t take care of yourself you are not going to be operating in a way you can take care of your patients. Make sure you have family and friends and healthy food, and to the extent you can, exercise and sleep and see a mental health provider, whatever is necessary for you to do well because this is a tough job. Try to maintain balance and realize you might be susceptible to depressive episodes and seek care. Also, find ways to channel your sense of injustice, grief, and sadness. Give yourself room for that.
• Dr. Poorman’s website
• What I Wish My Family Had Known About Medical Residency
• Congrats, Med School Grad! Now it’s Time to Find a Therapist
• Medical School Admissions Action Plan: 6 Steps to Acceptance, a free guide
• Accepted’s Medical School Admissions Services
• Endocrinologist, Writer, and Bollywood Critic Tells Her Story
• All About Duke Medical School’s Unique Curriculum and How to Get In
• Yoga Instructor, Holistic Health Coach, M4: Clare Brady Fits it All In
• Med School Uncensored: A Realistic Perspective on Medical Training
• Be a Happy Doc!