Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

This episode of The Nocturnists covers some pretty difficult territory. We hear stories of mental illness, suicidal thoughts, and even suicidal actions. So I really encourage you to turn this off if you feel like you're not in a space to hear that kind of thing. And if you do listen, just make sure to take really good care of yourself before, during and after listening. I also want to acknowledge that people can sometimes have really strong feelings about the language that we use to describe mental illness. And I want to point out that all of the storytellers in this episode use their own language and their own words to describe their experience.

Medical Student

I am a second-year medical student in Canada. I have both bipolar disorder and an OCD-spectrum disorder called trichotillomania, which is a big word, and it involves compulsive hair-picking (for those people who don't know). You can find a group for every identity category in medical school, like "being a woman in medicine", "being queer in medicine", etc, etc. But there's no group for being chronically ill or "mad in medicine."

But it can also be really hard, because you can feel so alone in your experience, and think you're the only one. I'm also really intentional in calling it "mental illness" rather than some vague idea of mental health challenges. Because I've been really sick at times in my life. I think the rise of wellness culture in medicine actually makes my shame worse, because it makes me feel like we're allowed to experience some kind of vague notion of burnout, maybe some depression and some general anxiety at some kind of subclinical level, that apparently you can manage with just some meditation and yoga and whatnot. But we don't want to actually name what is really going on for a lot of people. There doesn't seem to be a place for a crazy person like me, who needs medication before I can even consider doing things like meditation.

Emily Silverman

You're listening to The Nocturnists Shame in Medicine, The Lost Forest. I'm Emily Silverman. Today's episode is about shame and mental illness. And of all the episodes in this series, this was probably one of the most difficult to choose stories for because the theme of mental illness just came up again, and again, and again. Sometimes the theme was explicit. And other times it was more of a peripheral notion. But what seems clear is that these experiences are super common. So what is it like to be a clinician struggling with mental illness? To what extent is shame related to mental illness, a byproduct of the culture we inhabit? And what would it take for us to support ourselves and each other through these difficult seasons of life? Now, back to the story.

Medical Student

Anyways, here's the story I want to tell. During our psychiatry block, we, of course, learned about bipolar disorder. And I'll never forget the feeling of utter horror and shame when a slide went up on the impact of bipolar disorder, and it listed how, on average, people with bipolar disorder have, get ready, twelve less years of healthy life, fourteen less years of working life, nine less years of just life, two times the rate of employment problems, and two times the rate of divorce or separation. I know the point of the slide was to emphasize to our class how bipolar disorder is a super-serious illness, and should be treated as such, and I think that's really important, but I also just felt so ashamed of maybe becoming one of those stats. For example, ending up working and contributing to medicine, and taking care of my patients for fourteen less years than my peers and having twice the chance of employment problems, whatever the heck that even means. Yeah, and I was so thankful that medical school was on Zoom because of the pandemic, since I'm sure my face would have given me away as someone with bipolar disorder. I think this also gets to this bigger issue of notice in medicine, where it's like sickness is out there in the patients, and as doctor-medical trainees, we're totally immune. Obviously, that's not true. And I think that idea, that false idea, really adds to the shame a lot of us feel when we are experiencing illness.

Sometimes I hear my classmates talk about how their biggest failure was, at the time, getting rejected from medical school. And I don't mean to diminish how absolutely devastating that can be because I get it, but it also makes me feel so ashamed that my lowest points were things like being so crazy that I was asked to leave my job. It's caused me to lose relationships, and even want to lose my life. And actually, that even a lot of my successes and most productive times in my life have come from being mildly manic. So even my successes feel kind of shrouded in shame, since the truth is that they're in some ways due to being crazy. Not crazy-busy and crazy-productive in the way people kind of colloquially say, but literally crazy. Strangely enough, the people who've made me feel the least ashamed of being mentally ill in medicine are actually the patients. I've been shadowing psychiatry a lot, over zoom, of course. And I've met so many incredible patients, who suffer from the same or similar illnesses as me. And, I just feel so much empathy coming from them and just this non-judgmental attitude, even when they have no idea that I, too, have suffered like them. And this experience has really helped me realize that maybe being "mad" in medicine can actually be an asset, rather than just some embarrassing and shameful problem to overcome and hide. Maybe even one day I can share this story without being anonymous. Wouldn't that be amazing?

Jennifer Leah Goetz

My shame story takes place when I was a first year Child and Adolescent Psychiatry Fellow training in a prominent Boston-area hospital. I had done my residency training in General Psychiatry, and a chief year in Psychiatry at the same institutions where I was a Child Fellow. And at the end of my adult training, I had descended into a period of really dark, deep depression—the kind that I had spent my training learning to diagnose and to treat, and could recognize really easily in others. And I recognized it in myself, but had a profound sense of denial about what I was experiencing, that I, as a psychiatrist who dealt with this day in and day out, really shouldn't be experiencing these symptoms. I knew how to treat them, and therefore I knew how to get myself out of this.

But, as the depression got worse, I sort of sank deeper and deeper into it. And things that had been really easy for me to do became really difficult. My clinic, and emergency room, and inpatient notes were taking hours and hours and hours to do. I lived about two blocks from the hospital, and it usually would take maybe five to ten minutes to walk to and from work, but it was slowly taking more and more time. And before I knew it, it was taking me almost an hour to walk those two blocks because of how slowed down I had become. I wasn't sleeping and it hurt to move my body. Like, it physically hurt to move my body. Though I still continued my regimen of running every day.

As the days sort of blended together and became longer, and things became harder, my thoughts became darker. The work of being a Fellow was incredibly taxing. Our call schedule was grueling. And it wasn't infrequent that I was up for 48 hours at a time on call shifts, and it was wearing on me. My outpatients were wearing on me, as I struggled to help them and see progress in our treatment together. But my patients also were the thing that was keeping me tethered to the world, at a time when I was questioning why I was still here.

I knew that as my depression got worse and worse, that I wasn't going to be able to fix it on my own. And I knew that I was too sick to see someone, because I knew that anyone meeting me at this particular time would think I was too sick to be in outpatient. And I knew what that meant, as a doctor, and I wasn't willing to go that route, so I continued to get sicker. One day after a particularly grueling call shift, in which I skid off the road in a snowstorm, I texted my program director in the middle of the night and told him I needed to meet with him the following day, and I had planned to withdraw from the program, to quit. A wise mentor came with me, and she wouldn't let me quit. She said that I shouldn't make a decision about my career in the middle of a major depressive episode. And she was right, in hindsight. But in the moment, I didn't care. I just, all I could say was "I need to stop. I need to stop."

After that conversation, I saw my clinic patients for the day, and when I went to go home, my program director, and a couple other people, felt that I needed to be in the hospital. I think they understood that me "stopping" meant me stopping everything—meaning my life. And they weren't wrong. In what felt like a whirlwind, I found myself in the Emergency Room of the hospital that had trained me to be a psychiatrist, being asked the same questions that I had been taught to ask by the same person who taught me to ask them. I was wearing one of my favorite dresses that day. It was a, kind of, black and brown grayish speckled wrap dress. I had a little black slip under it and tights and little black flat shoes. The security guards, that I had spent hundreds of hours with on overnight shifts, asked me to take my dress off, so they could search me as they'd done patients we'd worked with hundreds of times before. Only this time it was me. And as tears rolled down my cheeks, I opened my dress. And at that moment, felt the most ashamed I've ever felt in my life. Because the place that I had trained, and the people who had trained me, were seeing me not as a strong, competent physician, but as a patient who was at bottom. I worried that they would never see me any differently. And I worried that I would never be any different again. That I would not be able to come back from this episode of depression; that I would never be a doctor again. And I worried that I would never be able to set foot in that emergency room again.

And so, as that night progressed and I was eventually hospitalized, in a sister hospital, my shame followed me. It followed me as a PGY2 resident asked me admission questions in the middle of the night. And it followed me the next day, when an intern, whom I had mentored throughout her psychiatry application cycle and was now working on that unit, saw me as a patient sipping coffee alone on the patio.

It's about two years since that period in my life, and I still struggle with depression. I struggle a lot with impostor syndrome, and shame. And I find myself drawn to residents, who I teach, who are struggling themselves. And it's not infrequently that I talk with them about the need to take care of themselves, and to find people in medicine who care about them as people. We have to help each other. And we have to make it okay to talk about these tough experiences.

Alice Weaver Flaherty

I am a neurologist, with a joint appointment in Psychiatry at Mass General Hospital in Boston. Oddly, this stigma of mental illness was kind of not even a problem for me until much later. My mental illness began after a very complicated pregnancy, in which both twins died at birth—one right before and one right after. And a lot of my sensation of loss, it felt like my, you know, my body wanted my twins back. And, of course, that brought to mind all the "wandering womb" things about hysteria. And I felt like my womb was wandering around looking for my children, and I would see them. Like, I would see a plastic bag blowing in the wind, and I would think that's my children, you know, like just these little scraps of windblown, you know, paper or plastic. I had a manic episode that lasted about four months after my twins died, and then right after that, boom, I got depressed. And it was just like a switch turned off overnight, and I was lying at the bottom of a pond or something. And it was actually quite peaceful. I was so exhausted from being manic. And I thought, well, you're not supposed to want depression here. I am wanting my illness. And so I must, I must, be making it up. But my psychiatrist, as soon as that happened, she was, like, "Oh, this is your depression; that was mania. Now I understand."

So then I had one of these cycles, repeatedly. It was pretty much every year, or some minor ones, but it was very seasonal. Every summer, I would get incredibly revved up, and then November, I would turn off for like three months. Then I felt the shame. All of a sudden, I realized I was a flawed doctor, I should not be practicing medicine, which had never occurred to me. And I got my forms for my license renewal at that point, and there was this question 16 saying, “Do you have any illnesses that might impair your ability to practice medicine?” Oh, oh my god, I do. And I couldn't think of anything really bad that I had done. I mean, I dropped someone's lung during a subclavian line a couple of years before, and there were some other things, but there was nothing that, you know, there was no no complaint against me. But I thought, I really need someone to monitor me to tell me whether I'm a bad doctor because I can no longer trust my own judgment at all. And I did go around and ask everybody, so I asked my mentor who I'm very close with, and she said, “No, you know, you're fine. You're worried that you're not, which is good, but you don't need to report yourself.” And a bunch of people told me that, including a forensic psychiatrist.

I even remember thinking: God, was I the only med student that believed it, when they said you shouldn't be ashamed of mental illness, that it's just an illness like the others? Because everyone, all the other doctors, would say, "Oh, I understand dear, you know, I understand, but just don't tell anybody else. Because there's a lot of stigma out there." And I was, like, Aah, that's bullshit, you know, and I started writing a book about my experiences, and so forth. But then the thing that got me was, I was pretty terrified after I wrote this book and published it, which very little of it was about my illness, but that's the part that everybody remembers. Like, it was a book about creativity, and there was, like, maybe five pages that were about me. And it became quite well known. There was even a photograph of me in a National Geographic essay on the brain. And so, like, I was sitting in people's waiting rooms. And I was afraid my patients would fire me.

What happened was really the opposite. And, even an old guy from Maine, and I think of, you know, Maine as being fairly rural and conservative, and he said, "Oh, I read about your, your kids dying. Oh, that was so sad, you know, and that going crazy part. That must have been so painful too. You know, my internist has that manic depressive disorder. And, you know, I have to get a temporary one because he's locked up right now. I think he was, like, running down our street naked or something. But he's a good doctor when he's sane, so I stick with him." And I thought, huh, that from a kind of person I wouldn't have expected that sort of, like, liberal tolerance, made me realize a lot of people are dealing with mental illness in their family, and it's way more common than I let myself believe, of course. So, that was very reassuring to me. I never have felt.... I've had patients mad at me, but not for being crazy.

First Year Fellow

Several months ago, I had packed my bags and gotten on a plane headed for home, after deciding to take some time off as a first-year Fellow. I was listening to a song by Abdel Halim Hafez, an Egyptian musician. The song, an old classic, called "The Coffee Reading" describes this encounter between a young man and a psychic foreseeing his future. She sees him spending his life chasing this beautiful, unattainable woman, a euphemism, of course, for wealth, power and other worldly achievements. It ends with the psychic telling him, "My son, one day you will return home, defeated and broken-hearted, realizing you spent a lifetime chasing but a trail of smoke."

Tears welled up in my eyes when I heard that. Was medicine a trail of smoke? I had dedicated most of my life to it, and yet I was going home, because I couldn't do it anymore. This didn't happen overnight, of course. It was the culmination of several months of burnout, isolation, and sleep-deprivation during my final year of residency. We've all experienced this at some point in our training. But how did I decide to cope with this? I was ostensibly leading a healthy lifestyle, eating mainly fruits and vegetables, exercising for an hour every day (and I mean every single day), so it was easy for me to remain in denial about my eating disorder. But I was slowly shrinking to minimize the space that my body was occupying in this world.

Thirty, forty, fifty pounds just fell off. It somehow felt like an achievement too. And, as my body continued to shrink, so did the rest of my life. The eating disorder had to displace my personality—my interests, my sense of self—in order to make a nest for itself. I felt ambivalent towards the life I found myself living, medicine included, and I started to dread—if not outright dislike—seeing patients. “Why am I doing this job if I don't enjoy it,” I kept asking myself. "What am I chasing?”

I suffered for months at first, too crippled by my depression to reach out for help. So I slipped under the radar, for some time. And during which my eating disorder cemented itself deeper into my neural pathways, of course. I felt like I was in quicksand. I kept telling myself: I'm a doctor; I should know better than to do this to my body. But it was no use trying to bully myself into eating. I thought I was fooling everyone around me, until one day one of my attendings, an astute rheumatologist, stopped me after rounds and said, "I'm not worried about your patient care, but I am worried about you. You look like you're fading away." She seemed genuinely distressed. I had become a trail of smoke.

She asked me more questions, listened intently before giving advice, passed no judgments. I began to realize that I had to do something if I wanted to save my own life. So I left the training program, and I flew 10,000 kilometers back home, unsure of whether I would ever be able to return. I spent two months at home, reading books, listening to other people's experiences, and just reflecting. Medications helped tremendously. And as I started to nourish my starved body and mind, the fog of depression slowly lifted, and I was able to contemplate more clearly on my experiences in medicine.

Despite what my sick brain would have had me believe, I did in fact love medicine at its core. I remembered how excited I was when I treated my first lupus nephritis patient. I remembered when one of my patients, a gifted artist, drew me this breathtaking picture of a mosque in Cairo, when I told him I was Egyptian. I love the sense of purpose that medicine had brought to my life, before my illness temporarily erased it.

It took a few months for me to find the courage to go back to work. But here I was, caring for others again, as a bigger and much better version of myself. Our trail of smoke has somehow become a paved road. There were definitely roadblocks at times, but it was ever present underneath my feet. Above all else, I realized how important it is to say something when you're concerned about a colleague's well-being, even if it's uncomfortable, even if you don't think you're that close. If we don't watch out for those who we're walking down this road with, who will?

Caroline Rose

September 1, 2010 was a Wednesday. I went to work in my clinic, seeing patients, before I picked up my kids to go to their piano lesson. Their teacher gave lessons out of her basement. They were nine and seven at the time, and they really loved going to their piano lesson. But I've often wondered if they loved going so much because their teacher had a Nintendo in her waiting room.

My son and I were playing games while my daughter was in her lesson. My phone rang. It was my mother, and I stepped outside to answer. It was one of those hot, bright, late summer days in Seattle, where the rain seems like a distant memory. I had to squint to see the phone. When I picked it up, all I could hear was my mother hyperventilating. Anyone who has witnessed a loved one having a panic attack, knows it's like having ice water injected into your veins. I froze, and words started coming out. "He did it," she said. "He did it." Over and over. And then, "He killed himself." Someone else picked up the phone, and said, "There's an ambulance here. They're taking your mother to Swedish Hospital." I dropped to my knees. I was suddenly in a reality that I didn't recognize, that I didn't want. I looked up and saw my seven-year-old son standing in the doorway looking at me. I hugged him and told him I was okay, but there was an emergency and we had to go. My father had been in the throes of the worst depression of his life. They had just left his therapist's office, and my mother was driving him there, to be evaluated for suicidal ideation. My father was 66 years old at the time. He had been practicing medicine for 42 years. He was a prominent radiologist. He was a leader in the field of ultrasound—really, one of its pioneers. He had published hundreds of peer-reviewed articles, lectured all over the world. But he had a secret. He had dealt with depression his whole life.

It would come and go, but it always came back. He had received treatment off and on. But mostly he self-medicated, as many doctors do, to maintain his secrecy. He once told me–proudly–that in all the years he had been dealing with his depression, he had never once taken a day off. I said, "Dad, I don't think that's such a good thing."

The last three weeks of his life, the depression was severe enough that he truly needed help, and he got it. But the shame he felt in asking for help was so profound, that in the end, he took his own life rather than live with that shame. Whenever I hear of a physician suicide, I wonder if that doctor also could not live with the shame of asking for help, for having the same needs as every other human being on the planet.

In medical school, we were trained to forget about our own needs and prioritize the needs of our patients. Hungry, tired, gotta pee? Take care of that on your own time, when the work is done. I know it sounds crazy, but we were rewarded for that level of self-sacrifice. And the flip side of that, taking care of yourself: Well, that was a sign of failure, that you weren't a good enough doctor. And all of us carried that ethos, through training and into our careers. And I think it's destroying us. That was the most tragic lesson I learned in medical school, not to say no, this is too much, I can't. And so I'm doing my best to learn that now. To say no, to put up boundaries, and to sometimes say I can't, and to have some self-compassion, to love myself for being human. In honor of my father, who never had the chance.

Emily Silverman

Thanks for listening to The Nocturnists’ Shame in Medicine: The Lost Forest. If you or someone you love needs help, call the National Suicide and Crisis Lifeline at 988. If you're a doctor or a medical student, you can also try the Physician Support Line at 1-888-409-0141 which is a free and confidential support line designed specifically for the physician community. Additional resources are also available below in our show notes.

Next week is our Shame in Medicine: The Lost Forest series finale. You’ve heard nine episodes on this topic leading up to today. What did we take away from this series? Where do we go from here? How do we move forward and create a better and healthier medical culture for future generations? Tune in for that, I think it'll be a really wonderful cap to the series.

To contribute your reactions and reflections to our shame series, and to access additional resources like transcripts, discussion guides, and more, please visit our website at thenocturnists-shame.org. Shame in Medicine: The Lost Forest was co-created by me, Emily Silverman, as well as Will Bynum and Luna Dolezal. It was produced, edited and mixed by Sam Osborn and produced and assistant edited by Molly Rose-Williams, with additional producing by Adelaide Papazoglou. Thanks to medical student producers Corinne April Iolanda Conn and Nikhil Rajapuram, production coordinator Penelope Lusk, impact campaign manager and assistant producer Carly Besser, and Exeter team coordinator Alice Waterson. The Nocturnists’ executive producer is Ali Block, and our chief operating officer is Rebecca Groves. The series illustrations are by Beppe Conti, and the music comes from Blue Dot Sessions.

Shame in Medicine: The Lost Forest was made possible, in part, by the Shame in Medicine Project at the University of Exeter, funded by the Wellcome Trust. The Nocturnists is supported by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org.

Our show is also made possible with donations from listeners like you. Thank you so much for supporting our work in storytelling. If you enjoy the show, please follow us on your favorite podcast app so you don't miss an episode. And while you're in there, you can help others find us by leaving us a rating and review. To contribute your voice to an upcoming project or to support our work with a donation, visit our website at thenocturnists.com.

I'm your host, Emily Silverman. See you next week.