July 15th, 2016
What Is Resilience?
Jamie Riches, DO
NEJM Journal Watch is happy to welcome a new panel of Chief Resident bloggers for the 2016-2017 academic year. Here’s a sample of what our new bloggers will be discussing, starting on August 1!
Jamie Riches, DO, is a 2016-17 Chief Resident in Medicine at Memorial Sloan Kettering Cancer Center.
“Resilience” is defined as the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress.
On March 9, of this year, my colleagues (my friends) and I unclipped our pagers from our belts, scrub tops, and white coats to read, en masse, “Important announcement at noon conference today.”
At that noon conference, we found out that one of our fellow residents had committed suicide by jumping from the hospital housing building. This intelligent, dedicated, accomplished young physician was the third internal medicine resident in our 22 square mile city to perform this act with identical detail in just under 2 years. We were dismissed to return to our pagers.
We picked ourselves up, literally, from sobbing piles on the bathroom floor and answered our pages. The work did not stop.
Throughout the following days and weeks, we were offered grief counseling sessions and open forums during noon conferences, where we could discuss our feelings and reactions. One morning, we were given free breakfast. We received many emails detailing these logistics, often ironically referred to as “housekeeping” items by the administration. We were desperately trying to clean up our own mess. The work did not stop.
After more than 3 weeks of waiting for the institutional silence to be broken, we were again called to an important noon conference. We were addressed by a senior physician lecturer. He spoke about depression and suicide, and how these things can often be inevitable, unpreventable. We were reminded that we are in a high-risk profession. A stack of handouts made its way around the auditorium, offering a prescription for resilience. We were advised to train ourselves to develop a positive attitude, to face our fears and find a resilient role model. This was followed by an anecdote, highlighting the speaker’s ability to receive terribly tragic news involving one of his family members and to walk directly into a patient’s room to resume work after hanging up the phone. The lecturer proceeded to present his research on resilience, largely based on studies involving military personnel and prisoners of war suffering from post-traumatic stress disorder. Correlations were made between entering the practice of medicine and entering the battlefield.
As the lecture proceeded, I began to realize that the traumatic event to which we were referring was not only our colleague’s suicide, it was our residency training. Unfortunately, this is not a correlation with which I am unfamiliar.
The forum was then open. “Please share your thoughts, experiences… and let us know: What can we do?” What can we do?
After a long pause, one of our most highly respected senior residents spoke, expressing his frustration with the fact that we were expected to resume work minutes after being informed of this tragic and shocking event. He stated that the perception of needing anything more than to take a deep breath and simply get back to work as equivalent to weakness, in combination with the “fear of retaliation,” was likely why no one was saying anything in this forum. This was followed by a reminder from our program director that “some people were given time off, and some people are still taking time off.”
This was true. One or two people had taken time off. We were not yet aware of what the repercussions of this time off would be. One month prior to this event, our chief residents had sent email to some of the senior residents: “If you are getting this email, it is because you have sick days to pay back. Sick days need to be paid back before June 30 so the program can sign off on your 3 years of GME, so please pick up shifts when you can.” Any resident who had taken a sick day in the past year was instructed to find time to cover an extra shift in order to “pay back” the institution for allowing recovery time. I had a flashback to another mass email referencing recent lateness to an outpatient clinic shift: “These instances are deplorable… You will become that person whom people hate to work with because of your lack of professionalism. Don’t turn into that, there’s already plenty of them plaguing our health system and we certainly don’t need any more.” These words were sent from those chosen to be our advocates. A wise, seasoned (and resilient) mentor of mine once gave me this piece of advice: “The institution will never love you back.”
Despite these examples, I don’t consider my program malignant. Malignancy in residency training refers to those programs in which the residents are placed in a hostile working environment. Despite having rapid administrative turnover (four program directors and three medicine chairs in 3 years), we have administers who are generally open to addressing resident concerns and who attempt to make changes based on resident feedback. This larger issue is not institutional; it is systemic.
I pride myself on my resilience. I am a New Yorker. I watched the Twin Towers fall on September 11, 2001, knowing that my family members were inside, saving others’ lives and sacrificing their own. I shared the grievous guilt of every family member, not only acknowledging that it could have been me, but wishing it had been. When I was choosing my own career, my father sat me down at an old wooden table at Chumley’s Bar and asked me if I thought I was “too good for the fire department.” My fear of fire is one I chose not to face. During my first year as a physician, my intern year, I received a phone call from my mother’s husband, informing me that she was in the ICU, and it “didn’t look good.” My mother’s life was plagued by a series of self-inflicted illnesses, and its culmination was that of multiple organ failure and a series of failed and futile resuscitation efforts. When I got the phone call that “it was time,” I walked into one of my patient’s rooms and informed him and his family member that I would be gone from the hospital for the afternoon because I had something to take care of. The patient’s sister replied, “I’m sure you’re very busy and have plenty of things to do, but this is his life we’re talking about.” I’ve cried every time I’ve lost a patient, someone’s mother or beloved family member, ever since. I continue to reflect on my disappointment with the overwhelmingly accepted notion that our training — the apex of our years of education, the threshold of our careers as physicians — is a traumatic event unto itself. Although, I know, in some ways, this is inevitable.
We enter medicine as if we are walking into a sacred space: hallowed halls where hierarchical gods prevail and miracles happen… until they don’t. We spent thousands of hours staring at computers and making phone calls and answering seemingly incessant pages, attempting to address questions to which we may not know the answers. We struggle to balance quality of care with quantity of care. We carry the underlying responsibility for the most vulnerable, most intimate moments of many people’s lives. This can feel like both a blessing and a burden. We not only carry people’s lives in our hands, we feel responsible for their deaths. We are tested every single day. Our knowledge, our patience, our compassion, our skill, our determination, and our stamina need to be demonstrated, examined, and verified. We struggle to find ways to work within a system that often feels punitive for its own faults. It can be lonely. It can be exhausting. It can be traumatic.
The Intern Health Study, a longitudinal study of depression among interns nationwide, estimated that “suicide rates among physicians are something like 40 to 70 percent higher in males and 130 to 300 percent higher in women.” Statistical estimates state that as many as 400 physicians commit suicide every year. Three young men and women leapt to their deaths in one city, in 16 months. We are not experiencing a tragic event; we are experiencing a harrowing trend. What can we do?
“Our needs are our greatest assets. I’ve learned to give everything I need.” – Andrew Solomon
The quote above is from a TED talk that, for months, I watched almost daily during my commute. This quote and many others gave me a great sense of comfort when I was grieving, tired, lonely, insecure, and burnt out. Looking back on those words, I wonder if the sentiment itself, or my attachment to it, is a reflection of the pathological need of the physician to feel strong.
I stood up to speak, not yet aware that my emotional state was one in which anything less than an [administrative] offer to turn back time would be received as an insult.
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.
What can we do?
- Eliminate the word “burnout” from the lexicon: Not only does burnout minimize the severity of depression, detachment and (at extremis) suicidal ideation among healthcare professionals (HCPs), it implies that those suffering post-trauma have some inherent flaw or weakness that impairs their ability to remain functional. This mindset removes the onus from the system.
- End the stigma: Remove the question, “Have you ever sought treatment for any mental illness” from the job applications. We should encourage residents, physicians at all levels, and other HCPs to actively seek out cognitive therapy as we do vaccines or PPDs.
- Decide what graduate education is: If residents are primarily learners, we must protect their time and use it solely for educational (both clinical and didactic) purposes and not to provide underpaid labor to perform all tasks for which the hospital is at a loss, no matter how menial. If residents are employees, we must provide adequate pay for educational level, protect sick leave, and outline contractual responsibilities before enrolling in the agreement.
- Stop penalizing unwellness: Physicians and HCPs are as human as our patients. We are not immune to everything. There will be times when we will be ill, physically and emotionally. We will need time and space to heal.
- Structure the system in a way that minimizes fear of retaliation: If the person creating or enforcing destructive policies is the same person who needs to write the words “excellent candidate” on the letter of recommendation that carries the weight of your future career opportunities, your best and worst interests are one and the same.
- Embrace our own fallibility: Learn to be comfortable with imperfection. Let us have an equal respect for our accomplishments and failures. Employ mentors who set this example.
- Accept that medicine is not martyrdom: The work does not stop. Let it not deplete us. Let us take care of each other and ourselves and not give away everything that we need.
“Recover” is the key word in the definition of resilience. Physicians are intimately acquainted with the process of recovery; recovery is a process. I do believe we will recover from this event, although not quite restored to our original state. We can work together to implement changes to not only create, but demand an educational and professional environment of safety, wellbeing, and, ultimately, resilience.
120 Responses to “What Is Resilience?”
2021-2022 Chief Resident Panel
Abdullah Al-abcha, MD
Mikita Arora, MD
Madiha Khan, DO
Khalid A. Shalaby, MBBCh
Brandon Temte, DO
Resident chiefs in hospital, internal, and family medicine
Learn more about Insights on Residency Training.
NEJM Journal Watch – Recent General Medicine Articles- Short Courses of Antibiotics for Patients with Ventilator-Associated Pneumonia
- Local vs. General Anesthesia for Elective Endovascular AAA Repair
- What Is the Incidence of Statin-Induced Diabetes?
- GLP-1 Agonists and Retained Gastric Contents at Endoscopy: An Update
- Still Double-Cover for Community-Acquired Pneumonia
In another country in the 1970s – for the SAME REASONS (suicides, stress, performance demands, vulnerability minimization, etc. etc.) there was virtually a student revolt against the faculty- it resulted in significant changes – short lived as they were. One crystalized notion that may help – IF we expect people to handle stress – we should equip them with the SKILLS to handle this stress. WE should protect those less adapt at stress management, and support those who have or are successful in developing these skills (performance under stress). They should be paced, rewarded, supported, and given autonomy to do things their way. They should be able to (honourably) opt out – as an alternative to self euthanasia. Three lives have been spent trying to convey a message to “the system” – can anyone help them get it?
Thank you for the comment. Pace is an important concept in the struggle, in which I think the global system is trying to find ways to be better equipped.
As a parent of a medical resident, this alarms me! It was my understanding when my daughter decided on medicine as a career that residency had become less time consuming and a little less stressful with time maximums being adhered to. Even with those time maximums, I find my daughter working 28 hour shifts, sometimes more than one a week. In a normally demanding job both physically and mentally, it amazes me that Doctors, new or experienced, are exhausted by the hours required of them too. I fear exhaustion on top of the stress and demands of the medical profession is “the straw that broke the camels back” in these suicide cases. The medical profession needs to look into reducing some of that added stress and exhaustion.
Thanks for the feedback and best of luck to your daughter!
As someone who just finished my medical internship at St. Luke’s Roosevelt, I still stand as alarmed as you. It is not shocking that our friend and colleague planned her death after finishing 2 weeks of her seemingly endless night shift where she got very little sleep and even less time for herself. What was shocking was that she had asked to take a sick day the night before her fateful decision and she was denied the time off by the administration that should have been her advocate — the same administration (and by that I mean program director) who she had been meeting with to tell she was struggling and contemplating suicide.
You go Girl!!! So beautifully done. After 27 years in practice, you have nicely framed all that I have lived, loved and hated. Be ware shedding light in the dark, resistance to change is strong. EMR/Coding Billing/ Medical neccessity/insurance and Pharmacy justification/pt Customer Satisfaction entitlement without lifestyle compliance/ pill pushing concept, big Pharma, the Opioid disaster/ lack of Palliative care education/ End of Life….. Still occasionally, I feel like I made a difference in someone’s life. Dan
Thank you, Dan. Glad to hear you are still (even occasionally) feeling the reward of making a difference. I’m sure it is more often than it seems!
Dear Mrs. Riches,
as a husband of a doctor I experience the described situation “from the other side”.
My question is:
Why not to change the economic, political, social situation/system?
In former time it was called revolution!
Has capitalism empowered the whole world?
When “The institution will never love you back” fighting against an inhuman system is the only possibility!
More power
Thomas
Thanks for the support. I think a culture change is certainly in order, though an all together “revolution” may be destructive to an already fragile system. We have to take care of ourselves, for sure.. but we also have to take care of our patients. I hope we make steps toward being better at both and I hope to be a part of that movement.
I think you need to address her a Dr. Riches Rather than Ms or Mrs.
Thank you for writing this. It is eloquent. It beautifully expresses what we need to change in medicine.
Thank you!
This is a beautiful piece, and speaks so poignantly to the backwards attitudes towards mental health in medicine today. I’m not brave enough to share my own story, probably because those same attitudes have left me feeling ashamed, but know that there are so many of us out there who relate. Thank you.
Thank you and good luck. I’m sure your story is all of our story in many ways, and is not one to be ashamed of.
So true. I recently left primary care because of all the administrative pressures and (non-medicine related) demands from business ‘experts’ and politicians who don’t seem to understand or care that American health care is getting sicker and sicker and that all these demands are driving physicians to the brink. I signed up to take care of patients not to make myself a martyr to a system that serves neither patients nor physicians. I haven’t looked back. I hope doctors everywhere will some day say no to the abuse and take back their profression for their own sake and that of their patients’.
what are you doing now? I left my hospitalist/primary care job a year ago, and am looking for a new direction. Any tips?
Outpatient primary care is my highest recommendation. Autonomy. Set your own hours. Done properly you can earn much more and work fewer hours.
As a family physician who has been in practice for over 20 years, I see the residency system has not changed for the better. The lack of humaneness with which residents are treated helps to create physicians that struggle to be humane to patients, let alone themselves. The “us” vs “them” mentality towards patients that results from the exhaustion and cruelty embedded in medical training spills over in one’s practice for the rest of one’s career unless it is consciously confronted and eliminated. Medical training should not involve a hazing process, but it does. We join a tribe this way as much as a profession.
Thank you so much Jamie for sharing. In particular, I thank you for sharing acting points–points that all residency programs could implement to relieve this “compressing stress”.
Your writing is excellent, and I hope you write more on what could be improved in this system of training. I always remind myself: “It doesn’t have to be this way.”
Thank you! As the dialogue continues, I would love to continue to add to the list of action points and then explore ways to implement them. Suggestions are welcome!
Thank you so much for writing this article. Meant a lot for me to hear my experience reframed in such a comprehensive, potent way that highlighted all the important points. And it was healing to hear once more, just like in an abusive relationship – it wasn’t my fault. The system is dysfunctional. I topped a 110 hour work week even with work hour restrictions, and worked up to 33 hours straight. Graduated in 2010 and now working a 3 day work week, much deserved and needed 🙂 Love, Vandita
Thank you for writing this. Incredibly well said. I blame myself for burnout all of the time, so it’s time to reframe and fix the system.
You have beautifully articulated the perennial justified suffering and stress of house staff. I recognize it well from my own experience forty years ago. The sad fact is that it is not likely to be fixable. The work does go on, every minute. The firehose of sickness and dying of hospitalized and clinic patients provides an unrelenting a 24/7 demand that is only going to get worse with demographic aging. In our system physicians in training do this work as a tough trade-off: they are learning their profession from it, they have the stamina of youth, and there is nobody else who can. Part of the shock is the rapid metamorphosis from student status to “soldier” status. You will acclimate. The burden will ease after residency but it never really ends. Welcome.
Thank you for this eloquent essay that contains so much painful truth. For you or anyone else who is not familiar with her website, here is the link to Pamela Wible’s website and blog: http://www.idealmedicalcare.org/blog/ Dr. Wible has been speaking loudly, clearly and frequently about medical student and physician suicide for a long time. Interestingly, her most recent blog post is about the inappropriateness of using the term “burnout”.
I graduated residency 5 years ago and quickly found myself burnt out by the expectations of the profession, corporation, etc. I cut my hours in half and cut my salary in half. I see 20 patients a day 3 days a week and have 1 admin day to do paperwork and other tasks. Best decision I ever made professionally. We can be in control of our own destiny in a toxic system. It also helped for me to realize that while our occupation is super important and what we do everyday truly matters, we are no more important than anyone else in society. All are needed and society can not function without all its pieces. This understanding allowed me to step out of the hero/martyr role and better understand who I was in my community family etc.
Some well made points. The institution itself appears to be unstable, creating a loss of balance felt by you and I suspect throughout. Your feelings are familiar to ALL who have been house officers, and most new employees of any kind. I would like to know much more about the screening process for who is being hired as house officers: perhaps psych screening at hiring & even throughout may be indicated in present times. Those who committed suicide may have been a round peg put in a square hole. I have not “fit” in various parts of life: most of us recognize the need to take personal responsibility for change. Michael Jordan (he and Larry Bird are the 2 greatest basketball players ever) just said “I’ve missed more than 9000 shots in my career, lost 300 games, 26 times I was trusted to take the game winning shot and missed. I failed over and over and over again in my life and that is why I succeed.” The following aphorism is a lifetime guide for adversity: “Perseverance is everything.” Sometimes adjustments are necessary. We each can & must speak for ourselves. Ultimately, life is about bravery. John McKay famous UCLA coach said of winning “It’s not a matter of life and death, it is more important than that”. A little humor and humility can go a long way. HRS, MD, FACC
Though I would advocate for providing required psychiatric and therapeutic support for all trainees as opposed to screening, I love the Michael Jordan analogy! Thank you.
Is there no one to complaint about this inhuman and slave like working conditions? Can the president of the country (or would be) be brought to understanding of the system and be highlighted on the fact that this is against all democratic principles and worse than the slavery practiced in this country years ago.
While all this is going on with the residents, I see so many nurses with less education and other hospital administrative professionals getting fat checks and working far far less hours.
Is stressing out the residents the only way for the hospitals to prosper?
Something must be done about this like a Medical Resident’s association or union and having demonstrations to bring some justice back into this system. Or set up a hall of martyrdom to remind the authorities and the general public of these atrocities in general. Otherwise, I see no hope for the future stars of this nation who work so hard for the health of this countrymen unless we do something about it.
Yes Andrew these are the right questions.
Just to say the medical system hired the ‘wrong’ people and have a little bit humor and stand up when you are down is not the way.
“Self-hardening” a philosopher (M. Gronemeyer) called it what the post-modernism is demanding from us.
But life is NOT about bravery its about trust!
Well Thomas, self hardening to the extent of crumbling into pieces is not the right way in general. What makes me wonder is whether state labor laws or fair employment laws even apply to the residents?
Who or how will anyone tackle this problem which seems to be an isolated case of a cancerous growth (specific to this profession) in an otherwise capitalistic social system that was designed to treat all employees equitably and fairly without undue stress and exploitation?
Again Andrew: the right questions.
Of course I don’t have the answers. BUT we have to keep on asking questions. That’s the part people down at the bottom have to do (or at least for those people who are at the bottom).
Therer are other people who are elected, in charge, responsible to give the answers!
Jamie,
I hear you.
Wayne
Thank you for the article. I’m 8 years out of residency. The stresses are not as acute or intense, but they remain. I feel I was pretty emotionally healthy as a resident, but the suicidal ideation has slowly grown as the chronic “compression” takes effect.
Your article gives me the vocabulary and analogies for many thoughts I couldn’t quite express. I think this will allow me to have a productive conversation with my therapist next week.
I don’t know if I’ll be able to have a frank discussion about these issues with the doc who owns the clinic where I work.
Matt – Thanks for your honesty in posting, and thanks for being a person noble enough to pursue medicine as a career. It is a tragedy that we are losing so many of these intelligent, caring folks who devote their lives to medicine. I almost went into medicine myself, but I did not due to the sickness of the system. It is shameful that so many in this field are depressed and suicidal. I am a social worker, and I worry greatly about my friends who are doctors. I speak from a personal perspective on depression and suicide, having been on the brink many times. Depression distorts thinking to where it can feel like there is no way out, and we are unable to see any solutions to our problems or any hope. Please continue to seek help for yourself and to make self-preservation the ultimate goal.
Hmmm. House of God rerun. When will we ever learn??
Nora Bartelsman. Family Doctor, Amsterdam, The Netherlands
PS. I, too have worked many times when I was really too tired, ill, upset to do so; just wishing I had broken a leg because only having a cast justifies sick leave. I have learned that sharing my problems with my patients is very benificial to both of us. Nothing wrong with saying…sorry, i really have to run off, my son has just had a serious accident and I need to go. I will ask a colleague to take over. Only sympathy. Patients know we are just human. We should start acting that way.
It appears you believe Santa Claus went with us on D Day or Iwojima . Frankly, your council is very questionable.