The American Medical System and Physicians 2: Professor Benoit Desjardins, MD, PhD, FAHA, FACR, FNASCI on the Poor Working Conditions for American Physicians

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): In-Sight: Independent Interview-Based Journal

Publication Date (yyyy/mm/dd): 2022/05/15

Abstract

Professor Benoit Desjardins, MD, PhD, FAHA, FACR, FNASCI is an Ivy League academic physician and scientist at the University of Pennsylvania. He is a member of the Mega Society, the OlympIQ Society and past member of the Prometheus Society. He is the designer of the cryptic Mega Society logo. He is member of several scientific societies and a Fellow of the American College of Radiology and of the American Heart Association. He is the co-Founder of the Arrhythmia Imaging Research (AIR) lab at Penn. His research is funded by the National Institute of Health. He is an international leader in three different fields: cardiovascular imaging, artificial intelligence and cybersecurity. He discusses: the poor working treatment of physicians in the United States; exposing the treatment of physicians; the biggest inroads in sheer viewership or consumption; productions; other proposals at every medical center hypothesized to help with the issue of overwork; the simple and obvious solution; working 36 hours in one period; working 90-100 hours in a week; the social life of the physicians; cruelty; patients kill their physicians; the level of burn out; some of the more egregious examples of (mis-)treatment of physicians; deceased or now-disabled colleagues; human rights violations; International Labour Organization; common statements from physicians; humane working conditions; and the future of the American healthcare system.

Keywords: American, Benoit Desjardins, death, Medicine, physicians, science, United States, working conditions.

The American Medical System and Physicians 2: Professor Benoit Desjardins, MD, PhD, FAHA, FACR, FNASCI on the Poor Working Conditions for American Physicians

*Please see the references, footnotes, and citations, after the interview, respectively.*

*This interview represents Dr. Desjardins’ opinion, combined to the current content of the published medical literature, and not necessarily the opinion of his employers.*

On the work conditions of U.S. physicians

Scott Douglas Jacobsen: What was the earliest known, to you, exposure to the poor working treatment of physicians in the United States?

Dr. Benoit Desjardins[1],[2]*: I realized it as soon as I started my training in the U.S. when I was forced to work 68h without sleep. I had been on call at the hospital two nights in a row, had worked 58 consecutive hours without rest, and was driving back home. As I crashed into my bed, I received a phone call from my chief resident asking me why I was not at the hospital as I was on call again for a third night in a row. I was unaware of it and explained the situation. He ordered me to get back to work. I drove back exhausted to the hospital and could have easily been killed in a car accident. I worked ten additional consecutive hours until I crashed on the call room floor. They found me unconscious later that morning. It was my first exposure to the poor working conditions of U.S. physicians.

Jacobsen: Who have been the most vocal people about exposing the treatment of physicians from 50 years ago to 10 years ago?

Desjardins: In the U.S., it was common for post-MD medical trainees (called “residents”) to work 90-100 hours per week and up to 36 hours without rest. In March 1984, 18-yo Libby Zion died at a New York hospital from a prescription error by a resident doing a 36h shift. It led to an investigation on the effect of resident fatigue on patient safety. New regulations were passed in 1987 limiting residents in New York to work no more than 80h per week and no more than 24 consecutive hours. In 2003, the ACGME (the body regulating medical training in the U.S.) extended the rule to all residents. They also limited resident calls to once every third night and implemented one day off per week. For comparison, in Europe, residents cannot work more than 48h per week. Note that these new rules only apply to residents in training, not to the U.S. practicing physicians who regularly work up to 120h per week and up to 72 consecutive hours without sleep.

Jacobsen: Of various productions about the issue, what ones seem to have made the biggest inroads in sheer viewership or consumption?

Desjardins: Around ten years ago, some physicians started to expose the poor working conditions of U.S. physicians. Dr. Pamela Wible noticed an epidemic of suicide among physicians, and she began accumulating data. So far, she has documented 1620 suicides of physicians caused by their poor working conditions, a clear underestimate of the true incidence of the problem. She publicized her results in a TED talk (“Why doctors kill themselves,” March 23, 2016), maintains a blog, and wrote books on the poor treatment of U.S. physicians. Since then, many articles, blogs, books, medical conferences, and documentary movies have covered the poor treatment of U.S. physicians. As a result of these initiatives, physician wellness is now a topic addressed by every U.S. hospital and medical school.

Jacobsen: There will be variations on a theme with the presentation of the same legitimate complaint of overwork and poor working conditions for U.S. physicians. However, some will ‘get’ it more. In that, they’ll hit the message and the reality, correctly. Which productions have been the most incisive and factually accurate?

Desjardins: On April 8, 2019, the New York Times published the op-ed article “The Business of Health Care Depends on Exploiting Doctors and Nurses” by Dr. Danielle Ofri. The op-ed discussed how the U.S. exploits healthcare workers with poor working conditions that would be unacceptable in other fields and countries. In June 2019, Dr. Pamela Wible wrote a book entitled “Human Rights Violations in Medicine,” tabulating and illustrating with real examples 40 different ways in which the U.S. violates the fundamental human rights of its physicians. It includes sleep deprivation, food deprivation, water deprivation, overwork, exploitation, bullying, punishment when sick, violence, no mental health care, etc. In 2018, Robyn Symon produced a documentary movie on physician suicide and poor working conditions entitled “Do no harm” (donoharmfilm.com). It is available for rent on Amazon and Vimeo. In 2004, Dr. Kevin Pho created a blog (KevinMD.com) on physician issues. Several recent articles and interviews on his blog have focused on the poor working conditions of U.S. physicians.

Jacobsen: What are other proposals at every medical center hypothesized to help with the issue of overwork akin to yoga mats?

Desjardins: The U.S. lacks interest in identifying and solving real problems. It goes well beyond healthcare and applies to poverty, violence, corruption, gun control, climate change, etc. Band-Aid solutions are proposed, and the root causes of problems are rarely addressed. Physician working conditions are treated similarly. Every hospital and medical school is now addressing physician wellness, given the massive levels of physician burnout. They discuss yoga mats, meditation, eating healthy, exercising, and sleeping well. But they don’t address 120h work weeks, 72 consecutive hours call shifts without rest and lack of access to food and water, physicians dying on the job, getting strokes on the job, destroying their health.

Jacobsen: Have any tried the simple and obvious solution by taking issue with the prefix “over-” in “overwork” to deal with overwork of physicians? 

Desjardins: No. There is a lack of interest in identifying the real problems and offering needed solutions. There is only one solution to the overwork of U.S. physicians: getting more physicians (or physician equivalent healthcare workers). The U.S. has 2.6 physicians per 1000 people (WorldBank data). The European Union has 4.9, ranging from 3.7 in the Netherlands to 8.0 in Italy, with much healthier populations. Despite the smaller number of physicians in the U.S., the country has the highest healthcare costs globally: $11K per capita in the U.S., compared to $5K per capita in the European Union. If the U.S. increased its population of physicians, the costs would rise since U.S. medicine is a business with unlimited spending. Hospitals have started to explore substituting physicians with less qualified healthcare workers to decrease costs. The frightening consequences of this approach have been well documented in the 2020 book by Dr. Al-Agba and Dr. Bernard, “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.” The book provides examples of poorly trained N.P.s and P.A.s, allowed to perform physician-level decisions and actions, resulting in preventable patient deaths.

Jacobsen: If working 36 hours in one period, what are the impacts, known in medicine and psychology, on the human brain?

Desjardins: Lack of sleep for 24h is, according to the CDC, equivalent to having a blood alcohol content of 0.10, higher than the legal driving limit of 0.08. Among the many side effects, it creates drowsiness, impaired judgment, impaired memory, reduced coordination, increased stress level, and the brain shutting down neurons in some regions. Lack of sleep for 48h affects cognition. The brain enters brief periods of complete unconsciousness known as microsleep, lasting several seconds. Lack of sleep for 72h will have more profound effects on mood and cognition and can lead to paranoia. Chronic sleep deprivation has a lasting impact on general health and creates high blood pressure, obesity, diabetes, heart disease, and depression.

Jacobsen: If working 90-100 hours in one week, what are the impacts, known in medicine and psychology, on the human body?

Desjardins: In a 2021 study by WHO and ILO, long working hours (> 55h/week) led to 398 000 deaths from stroke (35% risk increase) and 347 000 deaths from ischemic heart disease (17% risk increase). Dr. Maria Neira from WHO stated that “Working 55 hours or more per week is a serious health hazard“. Now imagine how much worst of a hazard for physicians forced to work more than 55 consecutive hours without rest. I cannot find any studies specifically looking at the health effects of 90-100 hours workweeks. Japan has the term “karoshi” to describe death by overwork, and employers are held criminally responsible for such deaths. No such laws exist in the U.S.

Jacobsen: Obviously, when everyone is stressed out and overworked in, sometimes, life-and-death circumstances, it is difficult to make an argument for consistent civility and reasonable social engagement. How do these working conditions – and work expectations – impact the social life of the physicians amongst one another, and the physician-to-patient interaction?

Desjardins: Overwork increases the divorce rate in female physicians, not in male physicians. Many physicians do not have much social life since they work constantly. They mainly interact with other physicians at work, not outside work. Sometimes burned-out overworked physicians have been rude to their patients, especially surgeons.

Jacobsen: Something easily wading beneath the surface here: Cruelty. People aren’t going to behave nicely, sometimes, in high-stress environments, where their life and livelihood are under question, including the health care worker. Although, it’s asymmetrical on oath alone.

Physicians take the Hippocratic Oath; the general public’s patients don’t. Also, a larger aspect is institutions. How were physician friends killed in the midst of maltreatment due to working conditions in medical institutions? How have physician friends been permanently disabled due to the work conditions?

Desjardins: Thousands of U.S. physicians have been killed or disabled because of poor working conditions. It has been extensively described in the literature. In my circle of colleagues, which extends beyond my current institution, three of my close radiology colleagues have been killed, all in their 30s, and many have been disabled for life. One was killed at work under circumstances that are still hidden. Two were killed in car accidents after driving back home in the middle of the night after their workday, completely exhausted. A colleague developed a stroke during his workday resulting in a permanent physical handicap. Another colleague was on his 97th hour of work on a week in which he was not allowed to sleep much or eat much. His body failed under these poor working conditions, and he became blind during work. He was rushed to the E.R., where they diagnosed a work-condition induced hypertensive urgency with bilateral optic nerve damage. They pumped him full of medication until part of his vision returned. But he remains physically disabled for life due to the poor working conditions.

Jacobsen: How many patients kill their physicians every year in the United States? How does this compare to other countries with metrics if any?

Desjardins: There are, unfortunately, no statistics on that. In my city, physicians are frequently assaulted by their patients. Some have been stabbed in the face, and some have been killed. The local news media almost always downplay it. Physicians are killed in other countries, too, notably in China. Physician suicides from the poor U.S. working conditions are also downplayed. When a physician jumps from the roof of their hospital, the local authorities simply throw a tarp over the body and don’t report it in the news media. Hospitals simply do not want the bad publicity from having a series of physicians jumping to their death from the roof of their hospital due to poor working conditions, like what recently happened in some N.Y. hospitals.

Jacobsen: What is the level of burn out in your field? What is the formal definition of “burn out” – whatever terms people want to use to describe physicians simply being taxed beyond reasonable limits and – not even requested – demanded to work more, as in your case?

Desjardins: The current level of burnout in my field is up to 70%. There has been a debate on whether physicians experience burnout, moral injury, or basic human rights violations. Burnout means physical and mental collapse from overwork. Moral injury indicates damage to one’s conscience when witnessing horrible conditions violating one’s moral beliefs or code of conduct. In 1948 the U.N. General Assembly adopted a Universal Declaration of Human Rights, a standard for properly treating human beings. Human rights violations are violations of the rules in this declaration. Physicians experience all three categories of injuries: burnout, moral injury, and human rights violations. It is a symptom of a toxic healthcare system, with working conditions massively out of compliance with safe labor laws from all other industries.

Jacobsen: What are some of the more egregious examples of (mis-)treatment of physicians?

Desjardins: There are many examples in the literature. Some U.S. physicians are forced to work up to 72 consecutive hours without rest. In my circle of colleagues, which extends well beyond my current institution, many of my colleagues experienced mistreatment. A physician friend recently started a new job in breast imaging. At the end of her first workday, which included a half-day orientation, they put her on probation for not reading her daily quota of 100 studies. At the end of her second workday, she became more proficient with her new work tools and read 98 studies, two studies short of her daily quota. They fired her immediately. Another physician friend was starting a new radiology job and went to lunch at the hospital cafeteria on her first day. She was forcibly dragged back to her work cubicle before eating a single bite, yelled at by administrators, and told physicians in her practice are not allowed to eat during the workday. Many physicians are required to work non-stop with no breaks for eating and no bathroom breaks and finish their regular workday in the middle of the night. They sometimes must sleep on the floor of their office at the hospital as there is not enough time to return home before their next shift. Dr. Pamela Wible identified several extreme examples of mistreatment: physicians being forced to work during a miscarriage or a seizure, surgeons collapsing on their patients because of dehydration and hypoglycemia because of their lack of access to food and water during work, and physicians falling asleep on their patient during medical rounds due to massive exhaustion.

Jacobsen: When speaking of your deceased or now-disabled colleagues, what happens to a body as parts of it simply shut down, especially in, basically, peak health years, e.g., the 30s?

Desjardins: For deceased colleagues, their body gets cremated or eaten by worms. For disabled colleagues, their health remains affected by the damage to their bodies for the remaining of their lives and deteriorates faster as they get older. They develop chronic diseases, such as high blood pressure, sooner than other workers, making their bodies deteriorate faster and increasing morbidity and mortality.

Jacobsen: For the UDHR, what human rights violations are discussed the most in the literature?

Desjardins: I would say violations of Article 23 (Everyone has the right to work, to free choice of employment, to just and favorable conditions of work), Article 24 (Everyone has the right to rest and leisure, including reasonable limitation of working hours), and Article 25 (Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food).

Jacobsen: Is the International Labour Organization, in any way, involved in rectifying these working conditions? Are there any countries anywhere with comparable working conditions, though, perhaps, lacking the advanced expertise and technological sophistication of the U.S.?

Desjardins: Among the risks for physicians identified by the ILO is “Physical and mental fatigue stemming from the specific conditions of this work” and “Danger of being violently attacked by unsatisfied patients.” So, the ILO has identified some of the risks and has proposed some solutions (Improving employment and working conditions in health services, 2017). In that paper, they discuss the European Union 2003 Working Time Directive, setting work limits to 48h per week, minimum daily rest periods of 11h, weekly rest of 35h, and allowing derogations for some doctors. They do not discuss the working conditions of U.S. physicians. Every country has different working conditions for physicians. India, China, and African Countries have difficult working conditions, given limited access to medical technology and the low physician to population ratios. But among the most industrialized countries (G-20), the U.S. and China have the worst working conditions for physicians.

Jacobsen: What are common statements from physicians about the working conditions? The emotional and psychological states rather than the facts and figures of the situation from colleagues who have survived, and continue survive, the insufferable work environment expectations.

Desjardins: The physician workforce has undergone a progressive zombification as it evolved within the current system. Physicians develop learned powerlessness to affect the system and deference to authority. They understand that working 72 consecutive hours without sleep is illegal and inhumane in every other profession except their own but are forced to do it by their hospital administration. They know that they will continue to become victims of crimes committed by corrupt prosecutors. They understand that the U.S. population is strongly anti-physicians and anti-science and will never be their ally. They know that the U.S. healthcare system is collapsing faster than anyone predicted. So, they bear the insufferable work environment and count the days until they can afford to abandon their medical careers or die on the job.

Jacobsen: Have American physicians simply left states to other states, even to other countries for humane working conditions?

Desjardins: Definitely. Physicians frequently move out of state because of working conditions. In some departments, large portions of several divisions leave en masse to practice elsewhere or abandon their medical career. Most would like to move out of the U.S. into countries with better working conditions for physicians, such as Canada, the U.K., or European Union countries, but immigration and licensure issues prevent them from moving abroad.

Jacobsen: What does this bode for the future of the American healthcare system?

Desjardins: The American healthcare system is collapsing. A massive shortage of healthcare workers is rapidly worsening, made even worse by the treatment of U.S. healthcare workers during the recent pandemic. The three-year probation time recently imposed by a judge on a massively overworked nurse for a fatal mistake will likely have a massive negative impact. These factors decrease the interest of foreign healthcare workers to move to the U.S., reduce the appeal of Americans to enter the medical field and make healthcare workers retire earlier. They have caused the development of healthcare deserts in 80% of the counties in the U.S., which lack access to the medical workforce, hospitals, or pharmacies. The present situation is bleak, but the future will be even more dismal.

Footnotes

[1] Academic Physician; Member, OlympIQ Society; Member, Mega Society.

[2] Individual Publication Date: May 15, 2022: http://www.in-sightpublishing.com/american-medicine-2; Full Issue Publication Date: September 1, 2022: https://in-sightpublishing.com/insight-issues/.

*High range testing (HRT) should be taken with honest skepticism grounded in the limited empirical development of the field at present, even in spite of honest and sincere efforts. If a higher general intelligence score, then the greater the variability in, and margin of error in, the general intelligence scores because of the greater rarity in the population.

License

In-Sight Publishing by Scott Douglas Jacobsen is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Based on a work at www.in-sightpublishing.com.

Copyright

© Scott Douglas Jacobsen and In-Sight Publishing 2012-Present. Unauthorized use and/or duplication of this material without express and written permission from this site’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Scott Douglas Jacobsen and In-Sight Publishing with appropriate and specific direction to the original content. All interviewees and authors co-copyright their material and may disseminate for their independent purposes.