Weinstein, Michael

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Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Surgery Faculty Papers Department of Surgery3-1-2018Out of the Straitjacket.Michael WeinsteinThomas Jefferson University, Michael.Weinstein@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: https://jdc.jefferson.edu/surgeryfpPart of the Mental and Social Health Commons, and the Surgery CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Surgery Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationWeinstein, Michael, "Out of the Straitjacket." (2018). Department of Surgery Faculty Papers. Paper154.https://jdc.jefferson.edu/surgeryfp/154PERSPECTIVE793Friction in the Path to Use of Biosimilar Drugsn engl j med 378;9 nejm.org March 1, 2018Out of the StraitjacketOut of the StraitjacketMichael S. Weinstein, M.D., M.B.E. I see him, maybe not so clearly. He is in isolation, in a strait-jacket. He’s just been committed, given a shot of haloperidol after he resisted going to the locked ward. He kicked, screamed, yelled, threatened . . . and now he cries.In the middle of elective inpatient electroconvulsive therapy for treatment-resis-tant depression, he had be-come profoundly depressed, delirious, and hopeless. He’d lost faith in treatment and in reasons to live. He with-drew to bed and would not get up or eat. He had to be committed for his own safe-ty. Several security guards had to forcefully remove him from his bed.He happened to be a 48-year-old surgeon who worked in an academic medical cen-ter. He had gone to medical school intending to become a family doctor like his father. He never imagined becoming a sur-geon; he thought surgeons were pompous, and that’s being kind. But he fell in love with surgery — the decisiveness, the immedi-ate “cure,” the bravado. He prom-ised himself he would behave differently from some of his edu-cators and emulate the many who inspired him.I know all these intimate de-tails because I am this surgeon-patient.My training occurred before work-hour regulations were creat-ed. Every-third-night call was the norm; every-other-night was com-mon. On one rotation, we were “rewarded” with being the opera-tive resident on post-call days, which extended our shift to near-ly 36 hours. On my trauma rota-tion, we took 48-hour shifts al-ternating with 48 hours off, to maximize the consecutive hours we could spend with family or friends. They call it “residency” for a reason, we were told.I became an acute care sur-geon, commonly known as a trauma surgeon. We are the ones who respond on a mo-ment’s notice to care for the seriously injured. We remove unwanted appendices as well as desired limbs. I remem-ber the pain, early in resi-dency, of witnessing a young man who had lost both his arms in an electrical inci-dent, but my recollection of the countless limbs I subse-quently removed is vague or nonexistent.We attend to critical ill-ness and have tools that save people’s lives, but sometimes I know I have used them to extend life too long. We face and witness death on a daily basis. We care tremendously about the welfare of our patients, their families, our trainees, our col-leagues and coworkers, though I haven’t always shown that care as well as I could. We often make decisions in the face of uncer-tainty that deeply affect our pa-2016, and growth in spending has been averaging 10% per year re-cently. Thus, competition creates the potential for considerable sav-ings — but if the impediments continue, important savings will probably be left on the table.Disclosure forms provided by the author are available at NEJM.org.From the Department of Health Care Policy, Harvard Medical School, Boston.  1. IQVIA Institute for Human Data Science. Medicines use and spending in the U.S.: a re-view of 2016 and outlook to 2021. May 2017. 2. Cohen H, Beydoun D, Chien D, et al. Awareness, knowledge and perceptions of biosimilars among specialty physicians. Adv Ther 2017; 33: 2160-72. 3. Federal Trade Commission Staff. Com-ment to the FDA in response to a request for comments on its guidance for industry on the “nonproprietary naming of biological products; draft guidance for industry; avail-ability.” October 27, 2015. 4. Baumgärtel C. Australian medicines authority positive towards biosimilar inter-changeability. GaBi J 2017; 6: 41. 5. Price WN II, Rai AK. Manufacturing barriers to biologics competition and inno-vation. Iowa Law Rev 2016; 101: 1023-63.DOI: 10.1056/NEJMp1714908Copyright © 2018 Massachusetts Medical Society.Friction in the Path to Use of Biosimilar DrugsThe 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. PERSPECTIVE794Out of the Straitjacketn engl j med 378;9 nejm.org March 1, 2018tients’ lives. When things went wrong, I frequently blamed my-self. I learned that doubt, igno-rance, and lack of confidence were my own failings.As attending staff, I still take 24- to 36-hour “shifts” of in-house call. A third to half of my week-ends may be spent in the hospi-tal. Early in my career, I even covered full weekends in the hos-pital, a 72-hour shift, in order to have more whole weekends with my family — and probably to demonstrate my machismo.One might have predicted my fall. I have had depression and dysthymia since my teen years. When I was a third-year resident with increasing operative inde-pendence, a couple of surgical complications threw me into a funk. I convinced myself that I shouldn’t be a surgeon. I wasn’t good enough, technically or cog-nitively. I didn’t have the forti-tude. I was a fake.I didn’t know what to do with these feelings. I didn’t believe anyone around me had similar thoughts. I didn’t know how to talk to my coresidents or faculty about medical mistakes and the accompanying self-flagellation. I don’t remember anyone talking about such issues back then.I was fortunate that my wife knew how to listen and under-stood my world. I endured. I com-pleted residency and fellowship and continued to endure for 16 years. Outside observers might have perceived me as “having it all”: a surgeon with leadership promise, with an amazing wife and two great kids, who’s paid more than I ever expected to earn.But enduring is not thriving. I had heard of burnout but didn’t really comprehend it. And though I had mental illness, I still saw it as a weakness, a personal fault. I remember early in my career hearing of a colleague who took a leave of absence for a “nervous breakdown.” I joked about it, said he was weak. Now it was my turn.My work lost meaning; I was just going through the motions. I thought everything I tried to accomplish was a failure. I had trouble relating to patients and felt the urge to avoid encounters altogether. I cared less and less about anything I was doing. I didn’t know it then, but I had long experienced classic signs of burnout: emotional exhaustion, depersonalization, and low per-ceived personal achievement. But the burnout had been waxing and waning for 22 years; now I was in the worst episode of ma-jor depression of my life.I wanted out, out of work and out of life. I wished I would get hit by a car, and sometimes took steps to increase my risk. I felt trapped in my work and worried that I would expose my short-comings if I sought a leave or disclosed my feelings. I’ve sub-sequently learned that my col-leagues were quite concerned about me but found me unrecep-tive to attempts to help. I was trying to get help in many ways, but nothing seemed to work.My functioning continued to decline until I could barely inter-act with others. My wife forced me to see my family doctor, who insisted I take a medical leave. I went electively to a psychiatric hospital. It was humiliating. I was scared, and I was certain my ca-reer was over.I went through a full course of electroconvulsive therapy and other treatments and felt better for a while. I even returned to work, prematurely. My depression came back with a vengeance. My severe psychological pain was unrelenting. I was suicidal and developing a plan to take all the pills I had. Even as I held onto the love of my children and wife, my brain told me they would be better off without me. I contem-plated death, though I feared the finality — perhaps death would be even worse than what I was experiencing.You would not be reading this today were it not for the love of my wife, my children, my mother and sister, and so many others, including the guards and doctors who “locked me up” against my will. They kept me from crossing into the abyss.I had convinced myself that I had end-stage depression, that there were no other treatments, My work lost meaning; I was just going  through the motions. I thought everything  I tried to accomplish was a failure.  I had trouble relating to patients  and felt the urge to avoid encounters  altogether. I cared less and less  about anything I was doing.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. PERSPECTIVE795Out of the Straitjacketn engl j med 378;9 nejm.org March 1, 2018and that I would be forever de-pressed, as I remember my grand-father being. Yet my healing has been considerable. I am happier and more optimistic than I have ever been in the past 50 years. I have never enjoyed being alive more than I do now, in each present moment.My family, supported by an expert-guided, trial-and-error ap-proach to pharmacologic thera-pies and compassionate cognitive behavioral therapy, opened my heart to a new perspective of  accepting and appreciating life through mindfulness philosophies and practices. I am discovering the habitual self-destructive pat-terns of thought that restrain my unconditional confidence.For over a year, I have been back at work in the same capaci-ties as before. I find daily joy in interactions with patients, their families, colleagues, trainees, and our health care team. I also find daily frustration in the workload, the amount of time spent in the hospital, the shrinking control we have over our work environ-ments, and the economic drivers in health care. I am concerned for future generations of clini-cians unless we change how we teach and practice medicine. We need to devote time and resources to promoting self-care. Too many physicians leave practice prema-turely. Too many physicians take their own lives.I have been open about my ill-ness and, though I had feared re-entry, I returned to a supportive and compassionate group of co-workers. I have learned that many of us suffer in silence, fear-ing the stigma associated with mental illness. I feel compelled to share my story, which I’ve found offers others an opening to ex-press their own suffering. I be-lieve that by deploying tools for reflection and self-care and work-ing together in a brave and disci-plined way, we can remove our restraints and isolation — both figurative and literal.Disclosure forms provided by the author are available at NEJM.org.From the Department of Surgery, Sidney Kimmel Medical College at Thomas Jeffer-son University, Philadelphia. DOI: 10.1056/NEJMp1715418Copyright © 2018 Massachusetts Medical Society.Out of the StraitjacketThe 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. 

Out of the Straitjacket.

Michael S. Weinstein

Crossref

New England Journal of Medicine