The following article has kept popping up on a number of my social media newsfeeds:
What Is Resilience?, by Dr. Jamie Riches. It is a poignant reminder to me of our vulnerabilities and of a system that both exacerbates those and struggles to respond to prevent these outcomes.
The papers I've linked this week are about this uncomfortable topic. I chose them, not only because they are recent, timely, and relevant--but because the author of two of them, Dr. Srijen Sen, is someone who trained a few years behind me at the University of Michigan. Beyond our common training however, we also shared the grief of the death of one of our peers, a mutual friend and co-resident who completed suicide in September, 2004. As our program reeled from the initial shock, we experienced the common questioning that ensued: "What did we miss? What could I have done? If only I had..." I think the theme that came out was that we had failed to see his pain because he had taken care to hide it from us, and when that became too difficult, he hid himself from us by progressively isolating and withdrawing. I often tell my depressed patients "Isolation is the Enemy"--and it certainly was in this case, preventing friends from seeing the need as well as curtailing the opportunities for positive connections that might have helped to alleviate his depression.
A Prospective Cohort Study Investigating Factors Associated With Depression During Medical Internship, by Srijan Sen, MD, PhD; Henry R. Kranzler, MD; John H. Krystal, MD; Heather Speller, MD;
Grace Chan, PhD; Joel Gelernter, MD; Constance Guille, MD. Archives of General Psychiatry, June 2010.
Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns: A Randomized Clinical Trial, by Constance Guille, MD; Zhuo Zhao, MS; John Krystal, MD; Breck Nichols, MD; Kathleen Brady,MD, PhD; Srijan Sen, MD, PhD. JAMA Psychiatry, November 2015
Dr. Sen, in these two papers, quantifies the burden on medical residents, specifically interns, and then shows on a smaller scale how a brief CBT-based intervention effectively reduces suicidal ideation in a similar group. I also attach a related editorial which makes certain recommendations regarding education, screening, and theatment. However, as I read these side by side with the refrain of Dr. Riches' editorial above--"The work did not stop"--I worry that sometimes we are just slapping band-aids on a deeper problem. I found her words haunting: "The resilience lecture began to feel less therapeutic [albeit well-intentioned] and more like a venue for perpetuation and exacerbation of a culture that was in itself, the compressive stress. We were being trained like soldiers, in the wake of our fallen comrade, to go out and fight! Be strong! Our strength was being measured by our ability to silently struggle through whatever we were experiencing and get the job done. Admit. Discharge. Admit again. We were being given tools to obviate the natural human state of vulnerability. We were “tasking victims with the burden of prevention.” We were reminded to be proud of our ability to charge on. I ended my commentary by stating that we were using the language of an abusive relationship."
Our work is hard and intense. Our systems, despite our best efforts, are flawed. I think our strongest weapon, though, is healthy, honest, compassionate, respectful, open interpersonal communication. Seek to become good listeners to one another, and be willing to share your own vulnerabilities as well.
Thanks for listening.
Links to Google Drive:
Sen, et al., 2010
Guille, et al., 2015
Goldman, et al., 2015
Thank you Dr. Oakman for taking the time and courage to share such a personal relationship to this topic. This story you share is actually one I can relate to as well: a faculty member where I went to medical school committed suicide recently this past year. It completely blindsided the faculty, residents, staff, and students. Again, those same questions you mentioned were immediately on the minds of all touched by this horrific loss. It truly does call into question our vulnerabilities, and, importantly, how the system seems to be letting us down.
ReplyDeleteThe article from Goldman touches on something I agree with and identify as a huge component to change. It seems to center around executing an idea. For example, the ACGME requires programs to have processes to assess fatigue and burnout and offer access to counseling. But, in executing this, the system fails. A requirement like this is simply not enough. The idea of specific strategies is where true benefit may occur - a great example is seen in the USAF efforts. What stands out to me there is that "leaders involved were easily identified and had substantial influence on the community." Again, I reflect on the orientation this July, and recall a single slide on resident well being and counseling services. There were some remarks made about reaching out if we had trouble. And, then it was back to business of training us in life support, deescalation, etc. It appeared the hospital was fulfilling its ACGME requirement but did we establish a framework of leadership residents could turn to beyond "tell your chief"?
What may be next is addressing a number if not all of the questions/statements Riches asks in her article. Her paragraph begins with "What can we do?" and would be fun to explore with other residents interested in wellness, resiliency, burnout... Being colleagues in psychiatry, I feel as though we carry a special sensitivity to responding to and acting upon the emotional (mental health) experiences of others, not just our patients. Can we work together in implementing some change at either HCMC or Regions?
I remember these articles something we should continue to work on in Psychiatry to lead the way for other specialties.
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