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?”
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Dr. Riches,
Thank you for this compelling article. In your opinion, what specific areas of medicine and parts of the residency process are the most daunting for young physicians?
Thanks again,
Jon
Jon, it is the culture itself that is the problem. There is abuse – essentially hazing. It is a culture where it is seemingly essential to be tough, to not show weakness, at your own expense. Where you are expected to work tirelessly and without complaint. Where 80 hour work weeks (which are the mandated maximum now) are considered easy compared to your seniors who “had it much harder” (and maybe they did). This culture wears on you – it definitely wore on me. At times, you’re mentally beat down and made to feel like an idiot. In the most extreme circumstances, you literally are told these things. But as a resident, there is not enough of a “speak up” culture because of fear of retaliation. You literally have no rights unless you have evidence of real abuse, like sexual harassment for example. If you don’t successfully complete residency, your practice options are severely limited. Once you’ve left a program or have issues with a residency program, you’re “damaged goods” and it may be very difficult to get another position.
This is the unfortunate truth, Scott. Thank you for writing.
Hi Jon,
I’ve been thinking about your question all week. I feel like the answer could be it’s own post!
I think one of the most daunting aspects is lack of autonomy when it comes to time management. You are never on your own schedule or your own time, whether it be to recover from illness, rest, heal, celebrate an important event or even to pursue an academic interest comes second to simply working. We certainly make the choice to enter this venue willingly and there are rewards that come with the amount of work put in. That being said, it can be hard to feel so removed from “the real world” for so long, and to see your friends and family move forward on such a different trajectory over the course of time. When the “work” involves more patient transport, phlebotomy or discharge paperwork than clinical investigation or direct patient care, prioritization and satisfaction becomes increasingly difficult.
I think I would be remiss in neglecting to acknowledge the financial burden. Many of us have taken hundreds of thousands of dollars in loans (at an interest rate higher than a bad mortgage), which we struggle to pay when making a resident salary. This is especially exacerbated in cities like mine, where the cost of living is exorbitant.
Overall, despite medicine being a stable and secure profession, residency can often feel quite the opposite.
Thank you for engaging in this dialogue. -Jamie
Competition turned into compassion sure would have helped my colleagues! We’ve got a long way to go.
Please see this illustration of How the word “burnout” perpetuates medicine’s cycle of abuse https://medcomic.com/medcomic/how-the-word-burnout-perpetuates-medicines-cycle-of-abuse/
This is a fitting graphic, Dr. Wible! Thank you for your continued efforts to bring awareness to the community. I respect and admire your work. -Jamie Riches
The Resilience you discuss is the same we face in the military. Neither of us have the option to mourn but are compelled to shake it off and continue the Mission.
Thank you for the comment, Walt. The correlation is one that I am aware of and explore often, in conjunction with my military friends. I think the military has made some exceptional progress in publicizing the need for mental health and making providers accessible to those in need. In many ways, medicine should follow that example. Thank you for your service. -Jamie
This is an American problem and it’s an attitude that exists in many areas of corporate America, even where lives are not at stake.
Thank you for this article. I lost my older sister, a surgical resident, to her battle with mental illness. The institution she worked at handled her illness poorly. I yearn for change within that system. Thank you for how clearly you’ve outlined how that change can occur.
Jill, my condolences for your loss and thank you for the feedback. Take care and my thoughts are with you and your family.
I wish the “What can we do” was at the top of the article. I think it is a great article and this translates to many professions. We just changed many laws in Florida to better address mental health and substance use (which was not mentioned, yet I am certain also plays a role). I believe stigma is the number one reason people do not seek treatment. The recommendations are right on target. However, until the stigma is removed, I fear little will truly change. Keep the conversation going.
Thank you Representative Peters for your feedback and your hard work to make changes in FL! I agree; stigma is closing doors for us and we are only harming ourselves by perpetuating it. I also agree that substance abuse factors in for many people, though happened to be unrelated to my recent direct experience. This is a much broader conversation that I am glad we’re starting to engage in.
It’s deplorable how little has changed since the days of “The House of God.” As a med student, I read it 3 times – once as a MS1, once as an MS3, and again as an MS4. I went into psychiatry and, though it’s not a perfect field, I never looked back. The culture of medicine is in desperate need of a major sea change.
well said — couldn’t agree more!
Thank you for a well written and thoughtfull analysis of resident life and the inadequacy of the administration response to it. I’m sick of the word burnout. It makes the situation be our fault, as you point out. I think a medical union is long past due; no one speaks for us with a unified voice, and so we can be divided and conquered. Plus, in a world where quitting or looking for another spot is seen as a weakness and a serious resume red light, we are hostage in programs that can treat us poorly because we can’t just walk away. And that doesn’t even take into account that we care about our patients.
Thanks for voicing our struggles!
After three years at Columbia College, applying professional option to ivy league medical schools and being turned down (the quota system was quite powerful, read the Anna.ls of the New York Academy of Medicine) I studied in Lausanne, Switzerland and Oxford Medical School. The systems are quite different from the United States. The malignant competition was not evident. A decency and grace towards students. The clerkships in France and Switzerland were respectful to students and residents. As chief resident at Yale, the system followed the European model. No suicides. The sadists who gain power in residency programs need to be removed.As we say in psychiatry:The arrogance of the insecure.
I am an old school physician and we knew going into medical school that we had to be cut out for it. Medicine we were told was not for the faint of heart. We were told it was a sacrificial profession and while empathy and compassion was needed the ability to save lives required us to be tough, to make sound decisions in tough situations…we were however taught by our seniors how to decompress how to destress…teams had meals together ..we celebrated every event…support staff made sure we were always ok…patients were thankful and respectful. So we worked hard…36 to 48 hour shifts…our Attending and seniors were hard on us…but we banded together in supporting helping each other..humor played a huge part..and the ability to realize that we were not infallible we were not expected to be…we just had to do what was right by our patients.
Prevention should begin at Pre med…education for potential physicians to understand the dedication and hardwork needed…the sometimes thankless work we do..how to cope..the need for other interests..venting..and finally to take time for yourself and your family..we used to remind each other….if you die today…we will have a few seconds of silence…then move on..as we are expected to do..and as we must. .because this is what we chose to do…so take time to eat right exercise time off time for family issues and recovery because like Beyonce says..we are not irreplaceable
Thank you for this well written and accurate portrayal of the medical profession. This unfortunately also carries to the veterinary medical side as well. To say a culture change is necessary is a complete understatement. I am sad to admit that toxic residencies and abusive relationships may be the norm in my profession as well. There is a silent and known expectation that a resident or intern must work hard and long hours, never complain, rarely receive a compliment or praise and to ‘suck it up.’ I believe the system is suppose to separate one who is good-enough/strong/resilient while the rest are weak. I believe this approach is outdated and extremely damaging.
The suicide rates and mental health illness in veterinarians are incredibly high. Overworked, underpaid, under appreciated, verbally abused and on top of that have an extremely high debt and (relatively low income for many general practitioners). The toxic environment of my residency has been unchanged for years despite the candid exit interviews by previous residents. I finished residency three weeks ago and am amazed I survived. I now start the next chapter of healing and recovery but am sad that a little piece of me is forever injured.
Thank you for this beautiful and candid piece. I hope it brings light to the dark side of our professions.
Thank you for writing this. I’m a medicine resident in NYC and I don’t think I ever realized why I sneered and rolled my eyes at our program’s emails offering residents “support” for mental health concerns and burnout, until I read this piece. We work in an abusive and patronizing system and I truly appreciate your highlighting some of the key areas where change can be made. I’ll be forwarding this along to friends and co residents.
I agree with everything you said, but at the same, because residency sucked so much, because it was so hard, so demanding, and I survived it, I now know I have the confidence and ability to handle what ever might walk through my (ER) doors. That whole “practice hard so the game seems easy” mentality. In fairness, I had an amazing support network in residency, and most probably don’t, but sometimes I wonder if residency had been less demanding, less taxing, would I be the same doc I am now?
As I finished my intern year of residency and entered my 2nd, I too began thinking long and hard on these above highlighted issues. I was inspired by an article in the Sept 2015 TIME magazine that featured a program initiated at Stanford to combat resident and medical student depression by creating a safe space for people to talk to one another, seek support and provide it for peers. With the encouragement of those in my program I instituted a similar concept at my program called “Humanity Rounds,” and this year as a final year resident I will be working to study its effectiveness in improving resident mental health and well being.
Please know Dr. Riches that I will be using this essay in our sessions, particularly the 7 points you outlined under “What can we do?”
Thank you for sharing.
I’d love to be able to correspond with you to get feedback and maybe even pick your brain a bit. You, and any others interested in what we are doing in Humanity Rounds, may please email me here: dbbeardmore@gmail.com.
Sincerely and gratefully,
Dan Beardmore, DO
To echo the many other comments here, thank you for this article, for not flinching in the face of abuse and grief and bewilderment. This conversation needs to happen, and you’ve helped build it.
I’m one of the residents who stepped back from the edge, literally as well as metaphorically. The week of Thanksgiving my intern year I found myself on the roof of the hospital’s employee parking structure trying to convince myself to jump. I couldn’t, and I cried the entire drive home. Four days later I was in a local ER with a BAC somewhere north of 0.3 awaiting a bed in a short-stay inpatient psychiatric hospital. It was the start of, to date, 20 months of medical leave occupied with therapy, support groups, psychiatrist visits, public health research, and thankfully no further instances of sucidial intent. It was, as it turned out, one of the administrators of my program — a sharply-witted surgeon who excelled at pointing out your faults, albeit usually humorously — who called 911 the day I was admitted after I had sent several worrisome texts to others in my program. The program, I can’t say often enough, has been amazingly supportive throughout this whole process: they got me help when I needed it, they listened to me afterward when I told them what I needed and how they could best help, and they’ve basically kept their hands out of my recovery, allowing me the time and space and professionals needed to rebuild that part of me which had fractured so severely. I’m not sure this would have been the case at another program, or even five years ago in my own.
So the system — if you want to call it that — can, and does work. I’m testament to that. I am alive because a handful of people recognized when I was in trouble and took the necessary steps. This is, I believe, the bare minimum any organization professing the represent the interests of medical professionals (residencies and otherwise) should achieve. Somehow I don’t think that’s the case. The compassionate and sincere attempt at support and understanding that followed is where they should be aiming.
There are still a lot of outstanding questions I haven’t answered. How did residency and intern year contribute? How could things have been noticed and acted upon earlier? In retrospect, there were many warning signs; perhaps these were unnoticed or misunderstood. How can we shift the focus of residency, and clinical practice as a whole, to a place that values both output and physician wellness, rather than output alone? How can we convince the skeptical among us that we flawed and fragile humans — as we all are, whether we admit it or not — are still capable of being competent, even excellent doctors? That we do our best work when our needs are fulfilled, too?
The pieces are there, I think. And they can work; they do work. They just need to work more, for everyone. It’s perhaps selfish, but I don’t want my story to be the exception, the one positive example of the system working to protect residents who encounter difficulty. I know I won’t be the last to find myself on the edge, and I’d like to think that –someday, with effort and education and comtinued will — all of us together calling out that it’s better to be alive, that problems can be fixed might do some good. Might help us hold on to the wonderful souls we currently are losing, every day.
Regards,
vs
This was beautifully written. From one physician to another, thank you!
Dr. Riches,
Thanks you for taking the time to write this article, it is very insightful. Unfortunately these are feelings that most will not understand unless they have gone through residency in our generation.
I want to point one thing out though. You mentioned that we are being trained like soldiers, to stay strong and move on. I would have to say soldiers are somewhat treated better then residents. During training in the army (based off my personal experience), our leaders made sure that we had time to refill our water, that we got a minimum amount of rest, and that we got to eat our meals. It’s actually a tradition in the (Canadian) military, that officers do not eat until the troops have been fed. There have only been a handful of times when an attending has ever asked me if I had lunch. In some ways the military treats their troops better then residents are treated… And i think your suggestion number 3 is a major reason why that is.
This is a fantastic article that gets to the crux of many of the issues we currently have in medicine. I’ve told several of my current colleagues about your article and bring up topics like this at times and feel as if I’m somewhat blown off. I just had a bad med school experience, or am too sensitive if that is even really humanly possible. The thought seems to be if we ignore that this is the world we work in, it will somehow go away. I think it is much the opposite; we must address some of these issues head on. Sometimes our greatest courage is needed to fix things from within our system and to advocate for ourselves and our colleagues. There is NO reason residents should be committing suicide, and least of which, should feel as if their program is dismissive of many of the factors that probably led to it. We cannot be fantastic and empathetic physicians for our patients if we can’t even treat ourselves with some self respect. I’m proud of you as a fellow DO as well! Keep on advocating for yourself, our colleagues and our profession!
Suicide in and of itself is tragic for anyone involved. To see a pattern in a small city should make someone ask “what the hell is going on”. Our healthcare “system” is broken. The residency program has been broken for many years and many of the doctors I know and have worked with would agree. Risk Management, that department that knows the details of what goes wrong due to a resident being exhausted makes for a horrible read. Now not everything that goes wrong is due to a resident, that is not my point at all. Patient’s who either haven’t had the “life style” talk or have had it and choose to not care for themselves but want every treatment available add to the problem. The fact that doctors who take part in trying to keep people living forever {perhaps due to their own fear of death} have helped create a society of people that do not know when to say …okay, I have had enough pills etc. Thank you for caring for me, for giving me your time and energy. And most importantly, thank you for hearing me.