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, I’d like to get in touch with you about this important topic. I work at the University of Iowa and produce a podcast with med students there called The Short Coat. Like you, we unfortunately have some experience with suicide. We would like to talk with you on the show about it. Please consider emailing me at david-etler at uiowa dot edu to explore the idea. Thanks so much.
Thank you Dave- I would love to be in touch. I’ll send an email tonight!
If it’s of interest to anyone, I am a survivor of suicide who speaks specifically to medical students and residents. My sister was a surgical resident at the time she began to suffer from mental illness. I tell my sister’s story of her struggle with mental illness and her ultimate loss of her battle, and make suggestions for reducing stigma, getting help, and offering support.
If anyone’s interested, I can be reached at jbarkley@gmail.com
The practice of hospital internal medicine has changed so much in the 16 years since I began residency. There has been a “creep” of responsibility where we are on computers doing our own order entry, documentation, billing, coding, answering “queries” from coders, fielding multiple inboxes, being expected to document in such a contrived way as to improve payer mix, round in a certain way, doing dumbed down mandated learning modules, etc,etc,etc.
I saw this coming my third year of residency when I rotated through the VA and my interns and I spent our day typing…just like my hospitalist associates and I do now.
Not surprising that today’s residents feel tortured. I did not, although I finished just before mandated hour limitations were put in place. Perhaps it was better because I was a doctor, not a “provider”, and certainly not a typist, transcriptionist, biller, coder, order entry clerk. I still love seeing patients but am glad I got in before the whole thing goes to hell as it clearly will.
The ancillary duties certainly interfere with being what most of us consider the definition of a physician. I’ve had some interesting dialogue about the word “provider” as well.. I think the direction is to be determined..
Hello: we will be speaking with our residents to bring this issue into clearer perspective for them. Dr. Riches can you email me so we can discuss ways to interact and communicate with them in a successful and meaningful way? Thanks in advance…
Thank you for the comment, Sarah. Please send your email and I’m happy to discuss.
Thank you, Jamie, for this transparent, honest post. As a pastor who works with healthcare students and professionals, I found your sixth suggestion (embracing imperfection) for fostering resilience intriguing. To say a bit more, I have found that healthcare students and practitioners struggle with perfectionism to an unusual degree. I.e., even though they appear to understand what’s taking place, they seem to struggle with being at peace with their imperfections. How do you propose that students and professionals address that? Thanks again for a great post.
Thank you for the comment, Bryan. I think accepting imperfection is a cultural change that has to come from our community, and (more difficulty) from within. The system is rigid and the timeline for success is pre-determined. We are competing, every day, for the next step in the plan: medical school, residency, fellowship, jobs.. and it seems endless. The stakes are high and “poor performance” not only effects our own lives, it (often and importantly) effects the lives of others, our families, our colleagues, our patients… As we and our mentors remain open to sharing our successes and our failures, my hope is that others will see this and embrace their own.. That being said, I don’t know the answers to many of these questions and I believe I’m just scratching the surface in exploring the questions themselves.
At the age of 37 after having left my university hospital 2 years ago, by accident I heard about a 44 y o colleagues suicide. We had worked together for 12 years. When I called my former head of dept he confirmed the information and filled in: “…and as we all know depression goes with a high mortality, like heart diseases etc.” That was all. The incident was “silenced”.
I called his wife to comfort her and we met weekly for one year. Then I understood that this tragic event was a direct result from bullying – by of the highest leaders of that surgical department.
I write this to help that such things never should happen again.
Kind regards
Margareta Berg MD PhD
Sweden
http://www.surgicon.org is the correct web adress
Apologies for your loss, Margareta.
The fucked up mentality.. They want to tease and take all the work from residents and take the benefit of their obsessions and compulsions.. residence as a dr is not an easy task.
Thank you so much for this genuine posting. Your suggestions (all, but esp #1,2,6,7) are doable and practical.
Thank you Beth!
Dr. Riches,
Wow!
Thank you for being so honest as I believe that is critical to changing this insanity. I train those in helping professions about compassion fatigue and the veterinary community is also plagued by this horrific trend of suicide, some say they are now the #1 profession affected by it. While human medicine has some different challenges, I see so many similarities that it is frightening.
Mostly that we (as a society and within organizations/institutions) are not recognizing the needs of the practitioner. But to that point, does the practitioner recognize their own needs? Through no fault of their own, healers haven’t been taught how to heal themselves and that is one place to start. For sure the “system” is in dire need of transforming as well.
Thank you for what you do.
Julie Squires
Certified Compassion Fatigue Specialist
http://www.rekindlesolutions.com
julie@rekindlesolutions.com
Julie,
Thank you for your comment. I certainly see the similarities in our professions. I will explore your website a bit and would love to be in touch further about your specialization as a Compassion Fatigue Specialist.
Take care,
Jamie
As a physician who has survived 2 episodes of clinical depression (2005, 2014), with suicidal thoughts and ample opportunity to act upon them, I can state unequivocally that the ONLY reason I am alive today, still practicing medicine, enjoying life, and able to write this, is that I was lucky enough to:
1- know the signs of depression
2- know how to access the help I needed
3- have the best possible care by a psychiatrist with experience treating physicians
4- be told: you WILL get better (so often that I started believing it)
5- be shocked into the realization that my death by suicide would ruin the lives of my children forever.
Talk to your trainees and colleagues about mental health. Share stories. Ensure resources are available and that doctors at all stages of their careers know how to access them.
Physician suicide is unacceptable collateral damage to the practice of medicine.
We are a caring profession, let’s show we care about one another too.
Not acknowledging depression and treatment without retailiation are at the core of the problems. 35 years ago patients were hospitalized to get a fall bladder ultrasound. Now though the numbers you see per day may be similar the severity of illness has increased exponentially! Patients are alive with EFs of 10, more patients survive on dialysis, I sent an old man to surgery for his third CABG! The work load has increased and the number of residents hasn’t. Result: depression, why couldn’t I save this patient for the umpteenth time. God Bless you all!!
Thank you, sincerely, for sharing your story, Jocelyne. Your advice is well-received and I admire your honesty. I could not agree more; we need to show our colleagues (and possibly ourselves) that we are not alone. All the best to you as you move forward in your career, and your life. Take care. -Jamie
I thought your use of the refrain “But the work did not stop” was particularly helpful. My question is: how do you think it can be handled in the future? Patients won’t stop needing attention and work won’t stop because a resident tragically ended his/her life. Who’s to pick up that work if the remaining residents cannot do it?
Other residents? I don’t think I need to comment on how this is not an option.
Fellows and attendings? But these are also over-worked people subject to the stress of the system.
Coverage hospitalists? From what I’ve seen of most hospitals, work force is in short supply. How do you propose that the administrators get emergency coverage?
Stop the work and let the patients fend for themselves? Again, I don’t think I need to comment on how this is not an option.
I get that this is very emotionally straining to go through. Is it a fix in the system that can actually help resolve the issue? Or is it really part of the job description, that this is an emotionally and intellectually intense vocation with very inflexible hours?
Perhaps the job description doesn’t need to be that way, if we had a much bigger workforce, but that would require a lowering the bars and expense of obtaining an MD and probably a cut in the MD compensation. I have no problem with it, but know many people who do, including people who probably share the sentiment as the writer of this article. So, is it a culture that can be changed from the within, or is it a broken system that is in need of an overhaul?
–someone who completed internal medicine residency 2 years ago
Thank you for the reply, Shelley. I don’t know the answer… I think most people would agree that the workforce increasing would lower the strain on physicians in general, including trainees and likely allow for more dedicated patient-doctor time. I agree that this is not likely to happen en masse in the near future. I think the financial issues alone could be a discussion all their own. To a certain extent, I do understand the commenters who state that we know what we’re getting into when we sign up, in terms of inflexible hours, limited compensation for decades, exceptional educational debt, little control over our own time (especially in training).. On the other hand, I think this system is doing a disservice to physicians, students/trainees and patients and is in need of an overhaul.
I always wonder about the training ,which was designed for learning and for hands on experience became so redundant with unnecessary responsibilities which were thrust upon interns and residents.. Buzz word is” hey you learn in residency” so whatever you been asked to comply by some rude, unkind seniors, fellows and attending will enrich your experience.
Everybody is aware of the problems and insane culture which is prevailing in each and every hospital but no one has solutions and as a result interns and residents are subjected unnecessary hardship and sometime they tragically not able to finish the training.
On one side we are promoting the culture of sound mental and physical health for our population and patients where we are totally ignoring the physicians in training! these interns and residents for days don’t get proper food and they only sleep 3 to 4 hr. There are inundated with not just following orders and implementing but also entering every-bit of information in computer, which is time consuming with little benefit..
why are we not opening more medical school producing more doctors when population and problems have increased many-folds. Why we think it is okay to go through such unhealthy training.
Thank you for bringing up a very appropriate and timely topic and it is about time we should work on finding solutions. Doctors in training should be treated and thought fairly without the fear of reprimand and rebuke.Unnecessary labor and redundancy should be curtailed.
I am a radiologist and foreign graduate however I notice the plight and stain/stress of internal medicine residents. Every body passes the buck by saying well it is training period and for their learning. Things have changed work has increased tremendously but work has not been shared fairly.
I once again thank Dr Riches for this important article.
There are no words to calm the storm of grief in the wake of a suicide. What is so painful is the truth that folks who serve with such dedication, purpose and love are suffering mightily well beyond the boundaries of their being before the fateful moment that ends life. The end of life doesn’t even speak to the tragedy of the enduring pain that preceded that horrific jump from the top of the building. Where was I when she was in a call room those weeks before, rocking silently with tears finding their way down her face, across her chest, and onto her scrub top? Where was I when the half-hearted smile, obviously forced, called for a snap, a twirl, and a hug? Where was I when a smart ass consultant made the unkind remark that made her feel less than whole? Where was I in conversation with the whole of medical education and culture challenging to integrity a vision of wholeness for physicians in life rather than indentured servitude? We never met my sweet one, but I know you and your life will not have been in vain – I swear it. To those of you who journey on, wherever you are, whoever you are, whatever your circumstance, my soul clings to the hope of our collective humanity reaching across this river of despair in presence with each others’ souls. In this space, we will breathe in unison, allowing our pain to simmer with watchful waiting for the comfort of healing. Our souls will become awash with the healing of combined strength; seeing the scar, feeling it, knowing it and remembering it. This I do with you in this moment and any you require. When we are connected in this way, the pull of your soul, if unable to surface for life-giving oxygen will find rescue among the others; no judgement, no scorn – Just caring – Just loving. I’m not sure, dear students, interns and residents that you know just how much I love you. Dr. K
so well written. Kudos to you for joining this fight for our lives. don’t let the system change you. You nailed this!
Poignant, eloquent, truthful.
I think this illustrates the further mechanization of medicine “the work did not stop.”
Physicians are supposed to be perfect. Mistakes are unacceptable, and if an unwelcome outcome occurs, all parties involved are subject to protocoled review and remediation. Is it the same for our own emotions?
Is the perfect physician (in the eyes of the patient/ institution) one whose world revolves around her patients and their needs at the expense her own. I think this is how may of us start out, with those altruistic dreams of healing with our hearts and souls even if our medicines fail.
But so much of this for so long, especially without genuine reciprocation, can just hollow you out.
If we are just starting out, the burden of learning life and death (and the consequences of both) is a rather traumatic experience in itself, as Dr. Riches insightfully points out. It is our responsibility to appreciate that newness and how impactful it is on our lives. If we are more experienced, we cannot forget what it was like before we became more resilient (or, possibly and sadly, before we accepted the hollowness).
Rather than huge mandatory gatherings at scheduled times or times of crisis (so that appropriate paperwork may be completed), we should look out for each other every day. We should let our mentors tell us how they grieved a patient’s death, and how they juggled a busy clinic day with sick child at home. And we should listen to our students as they struggle with a never-ending work load, and juggle the interpretation of lab results, a migraine, and strained relationships at home.
As so many have already said, the most important things happen in the day-to-day. So when we pass our colleagues in the halls and say “how are you,” we should pause for a moment and really mean it.
Residency is an antiquated system. In a perfect world, education would be the top priority and taking half an hour to do a literature search whenever you admitted a patient would be the norm. Work output should be a very secondary goal saved for the final year of residency when you’re competent in clinical skills and can focus on learning the ropes of the business of medicine. I don’t know how the hospital budget would need to stretch to allow this to happen but seeing as how the majority of residency positions are funded by medicare, I see no reason why residents should put the work output goals of their hospital ahead of their own educational goals. The hospital doesn’t pay their salaries.
I could not agree more, Joel. The service vs learning conflict is difficult to balance and, in an ideal world, they would simply not conflict.
Good article, but I noticed you don’t call for any further reform of working hours. Isn’t it necessary to allow residents to work a reasonable number of hours per week? Too much work and too little sleep leads to physical and mental health problem. Sure, “the work doesn’t stop” –there’s a lot of work to do. So then hire more PA’s or NP’s and let more people into medical school. Doctors have human rights too.
The italics of
“The work did not stop.”
was incredibly powerful.
Residents’ labor and time on call is a resource. It really sounds like every manner of socioeconomic coercion and bullying is being used to transfer control of that resource from the residents to the senior medical establishment and hospital administration. If the job of the hospital team is saving lives, anyone on the team who has an excess of luxury and choice, while so many in the team are working on the border of self-destruction, is *stealing from the team* and *stealing from the mission.* The incentives of the people who control the GME process need to be examined. The incentives of the people who control the supply of residents and demand for their services need to be examined. Because this smells like people with power acting under a huge conflict of interest. This does not smell ethical. This does not smell kind. This does not smell like the work of healers.
As a mother of a Medical student who killed himself this past Mother’s Day. I agree we need to change the way Medical student’s are educated. We need to teach students it’s okay to fail at something. Life’s not perfect nor are they perfect. Also everything in life doesn’t always turns out the way we want. However medical students are highly intelligent people where failure is just not a option. With that said maybe we could teach students more relaxing techniques. Maybe make them all do yoga daily or something else. I don’t believe any student is going to seek help if they feel it’s going to go against them. These students don’t want to look weak. I had a few medical students at USC/Keck who were friends of Sean’s tell me way after his Memorial that was held on the school campus. They were sorry they had avoided me at the Memorial. They didn’t want they’re fellow students and professors see them break down. How sad it is they couldn’t show any emotion at a Memorial. Then how can we expect them to seek help for depression if they have to look strong even at a Memorial for a friend’s death. It has to become a standard screening for all students. You also have to think as they do why seek help it’s just going to go against me when I apply for my medical licenses or when they go for their DEA license and Malpractice insurance. At those times they are asked if they’ve been treated for mental illness. If they tell the truth they stand the chance to get denied everything or put on with very limited powers. I don’t understand why they are allowed to ask this question. We have HIPPA laws why can’t we have where doctors only have to disclose if they’ve been treated for schizophrenia. As a patient I wouldn’t care if my doctor had been treated for depression.
I would like to have the medical schools have to inform both incoming students along with family that suicide is possible in medical school. I never knew anything about this problem until my son’s death. This was too late to save my only son. I wouldn’t want anyone to go through what I am going through. Sean had to be in such pain to hang himself. He put himself out of his pain by killing himself. He just passed his pain onto his stepfather, friends, extended family and myself. We all live with this pain daily.
I’m so sorry, Cheryl. Your story mirrors parts of my family’s story with the loss of my sister. I am so sorry for your pain.
The stigma of seeking help is very real, and can have career implications – which is wrong.
Dr. Riches,
Thanks so much taking time to record your thoughts and feelings in this article. It is an exceptionally well encapsulated glimpse of residency. In simple terms…you nailed it. A few of my co-residents and myself are working on a wellness and resilience initiative in our residency and your list of solutions helpful in framing some of the goals we want to accomplish. As you recognize in many of your responses to follow up comments, the issues require changes at many levels of the system and the culture and your Addition to the commentary is quintessential.
As a side note, AM rounds (Academic Medicine’s journal) has recently sent out a call for letters to the editor. I think your article would be very helpful/well received there. Just a thought.
Academicmedicineblog.org/call-for-letters-to-the-editor/
Great blog