Medicine From The Trenches

Experiences from medical school, residency and beyond.

Suicide

I have wanted to push this post out for many months. This is very difficult to write about because I am still so close to the raw emotions and feelings. I want my readers to understand how much many of us who take on the task of teaching others medicine care about our teaching and our students/trainees. This was very close to me and stays with me because the young person that I write about left behind two young sons and a young spouse who is somewhat adrift even today when I spoke with them.

I met this young resident physician when they entered the program where I teach. That first day when everyone met and introduced themselves as we all sat around a large oval table. The PGY-1s and the faculty members who would get to teach them and get to know them. The resident was full of hope and anticipation being so happy and grateful for a match into our program. Everyone was so hopeful even knowing that residency pushes one to limits physically and intellectually in the case of surgery. Many believe that the major test of medical school is the measure of a physician but residency is where practice begins and starts the foundation of what will be a life of practice and learning. While medical schools gets one ready for residency, the experience of managing patients and performing surgical cases first as surgeon junior and then as resident is the making of a surgeon.

This resident started out on a ward-intensive rotation under a chief resident who was a patient teacher and generally supportive of the junior residents and medical students who were on the service. All reports were good and the resident was progressing well-not superior but more than adequate. All PGY-1 residents need to sleep more, read more and get out of the hospital as much as they can. The faculty in our program work with the chiefs to make sure that the workload is challenging but not oppressive. I love to do patient care along with my residents because I love taking care of patients. On many weekend mornings, I round, write my own notes and inform the chief of what I have been doing so that the junior residents and medical students are not so burdened.

By the end of the first half of the first year, all of the new interns (PGY-1 residents) seemed to be getting into a groove. The major services: general surgery, colo-rectal surgery, minimally invasive surgery and surgical oncology, were humming along well. The specials: vascular, pediatric, thoracic, critical care, cardiac and plastics were well-covered with interesting cases and patients. It seemed like the year was going to roll along in that predictable manner so that we could all gather at the end and make fun of ourselves while sending the graduating chiefs off in appropriate fashion.  Mid-way through this year, one of the new interns started to unravel a bit. I was asked to do a bit of counseling and unloading. I am happy to play this part for the program.

It is a general fact that most interns will not ask for help when they are getting overwhelmed, especially in a surgical program. There is the code of the surgeon being tough and resilient, thriving under pressure and invincible. Some of my fellow attending physicians still subscribe to this code of conduct but I am having little of this. I love showing my vulnerable side, and often do,  because it enables me to show my strong side at the same time. Yes, I am a human being that is the same as my patients and those I train. I learned from a very wise surgeon colleague that I have to allow those who encounter tragedy and stress to decompress immediately and to keep decompressing. As a leader, I owe this to those who work with me in this profession.

The intern seemed to have a difficult time dealing with the night float where one has to shift rapidly to cover the incoming patients. On my call nights with this intern, I would generally cap their load so that some rest and learning could take place. I calculated the average for the past week and capped when that number was met. Anything over the cap, I admitted, worked up and handled with the chief resident. This generally didn’t amount to many patients but it created a sense of teamwork and accountability for all of us. I loved presenting new patients in morning rounds and having the chief question me (same as the interns) about management. This is a great experience for all of us and continues today.

Along with difficulties on the night float service, personal problems at home began to creep into the picture. The spouse was having an affair and the children were feeling the effects of the strained marriage. Being single, I am surely not equipped to counsel anyone on marital stresses but I did strongly encourage this resident to seek some outside counseling. I assured this young physician that I would be as supportive as possible in making sure that my colleagues understood the grave nature of the home front problems without betraying any confidences. I know of great love and feeling for another person and the loss of that person can be raw. I also know that every person deals with loss in different ways and that with the stresses of a surgical residency, seeking some marital counseling is probably a sound idea.

Three week later, this intern was still trying to balance work and family struggles. Things were unraveling and I suggested taking a leave of absence for the remainder of the year. When things can’t be worked out and work can’t be done, a leave of absence is often the best solution. This was arranged by the program director with an offer for this resident to attend teaching conferences and educational classes as much as possible. We offered a research position that had been left by another candidate so that this resident could have some income. We all offered support and fellowship but substance abuse came into the picture.

I don’t know how substance use began but I noticed the smell of alcohol during one of our educational conferences. I immediately asked the resident to leave because the smell of alcohol can’t be on any physician who is in a clinical area without exception. I was deeply disappointed but asked to chat the next day when possible. The resident never contacted me. Later an admission for overdose of opioids (deemed accidental) along with alcohol. I rushed to the emergency department to find the resident semiconscious and unable to communicate. Clearly, as I spoke with them later, I emphasized the need to spend some extended time in counseling but I could sense a drift away. The shame of losing a training license and a residency position was more stress and deeper into a despair that I was not equipped to handle. I begged this fellow human being to reach out for the sake of the family and children.

Medicine and medical school into residency and practice attracts a person who becomes comfortable with work toward long-term goals. One has to have a high degree of comfort with the long term process because the journey is long. Along the journey goes the family and friends but the resident is the common factor. I know that my colleagues who have families are happiest when they spend as much time as possible with those families. One of my colleagues always says that he can’t understand where my recharging takes place (my spirituality, my adventures and my sheer wonder of all things as I go through this life). This experience rattled my entire experience with medicine and still does.

When this resident committed suicide, I plunged into a depression that only my faith could keep me going. I prayed myself to put one foot in front of the other one so that I could get out of the door of my house in the morning.  I know intellectually that I couldn’t force another adult human being into making better choices but I still can’t fathom leaving behind precious children. It is my firm belief that children can weather the disintegration of a marriage if the spouses involved are dedicated to raising them. I also believe that children only want your time and unconditional love (my experience with my nephews). In honor to this resident who felt so much pain and was unable to get the help needed, I listen intently to my trainees. In honor of this resident, I search intently for any shred of hopelessness in my colleagues, residents and students. In honor of this resident who was kind to their patients and to others, I strive to be kind to others. In honor of this resident, I try to learn the lessons of life and to be thankful for life.

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30 June, 2015 - Posted by | general surgery residency, intern, residency | ,

19 Comments »

  1. Thank you for writing about the sense of shock and emotional turmoil from this. I have read your blog off and on since I was a medical student and respect your logical writing and consistency and your wisdom. I came searching for this because the chief resident I “worshipped” as a medical student and the one who got me interested in surgery in the first place killed himself relatively recently. I think about it more often than I would have thought likely. I wish I had told him how much he mattered to me and how I try to follow his example during my own chief years. I wish he were still with us today. It still baffles me when I wake up and realize I can no longer email or text him for advice and I wish I could have helped him, although I guess he was sicker than any one person could really help.

    Comment by N/a | 24 April, 2016 | Reply

    • Thank-you for your comments. This was very difficult and has stayed with me since it happened. We must take care of each other even if it feels uncomfortable.

      Comment by drnjbmd | 26 April, 2016 | Reply

  2. Dear Dr. Dmjb,
    Thank you for sharing this and also thank you for your advise 2 years ago. I did not match for the first year with 8 interviews but did match on my second year with 6 interviews.
    I think I would like to share a little bit about my internship experience.
    First I was not totally happy with the program I matched into. I thought I was too good for that program. First few weeks, I was a little bit cocky but then later realized that my co-interns are pretty knowledgable I still need to learn a lot. I was later stressed out by the work load and fear that with any of my mistakes can cost live of my patients. However, I did not know how to ask for help. On one hand, i wanted to handle it all by myself and on the other hand, I did not know how to find support. There were times I handled the situation all by myself where there should have been a rapid response. I have been lucky so far. I was stressed, I stayed late for most days-worked outside my duty hours just to make sure I did not make any mistakes. i did not have a life. At the end of the year, I was almost burned out. I had not read anything to keep up and I felt like I had no medical knowledge so far. I have zero self confidence.
    So now is the beginning of my resident year. I still do not have any motivation to study. Worse, I lost my passion. I get easily annoyed by patients who complain about their pain for hours at clinic. Every morning, I promise myself that I would be nice to my patients and would do anything to help them. Before the evening, I’m not sure I keep my promise or not. There are times I need to remind myself whatever I do make a difference in these patient life. I used to be passionate even tough I used t be indifferent to other people pain. The more the complain, the less I care. The less the complain, the more I work hard to take care of them. I am still confident that I can change.
    BTW, now I love my program. My assistant PD is amazing. She is aware of what I do from what test I ordered, what care plan I missed to what I did during ICU rotation at night. I am relieved that someone is watching and that there is autonomy and balanced supervision.
    As an intern, all I wanted from my attending is the support and the balanced supervision in my decision making process and also the knowledge that he/she would teach me when I make mistake instead of punishing me/making me think that I have no knowledge and a happy family like environment.
    From what you wrote, you provided all these support to your intern. In my humble opinion, now all what you can do is help his children if you can. You cannot save everyone.
    Again, you have helped a lot of people like me and thank you so much for that Dr. Dmjb.
    struggling resident.
    (PS. sorry about my long story and run-on sentences. I’m not good at writing and English is not my first language 🙂

    Comment by Sandar | 25 July, 2015 | Reply

    • To Sander:
      I suspect that you need to take the next weekend that you have off to think about why you entered medicine. I suspect that you entered medicine to take care of your patient’s problems and therein is your motivation. On your next day off, take some time to get away from medicine (and all things medical) to let your head clear. Think of the thousands of ways that you touch the lives of your patients even if you are just trying to get the job done. They put their trust in you and look to your for connection. Make that connection even if they are angry (and direct that anger towards you)because of the disease process. Remember that they are there for a million reasons but not because that chose to be there. Remember that you have been granted the privilege and knowledge to make a true difference in their health.

      Take some time to find something outside of medicine where you can renew your spirit. I learned to fly when I was a resident. There is nothing like contemplating the world from 8,000 feet above to gain a new perspective. The challenge of mastery of flight was a true relief for me.Play some music or play a sport (lacrosse and soccer kept me sane too). By not relying on medicine to meet all of your needs and having a strong spiritual outlet (find a church/religion/faith) that speaks to you if you don’t have one already, you can move outside yourself and see the true magic of connection with another soul, especially one that suffers. Take the time to meet your spiritual needs (schedule these things in if you have to) so that you have some balance.

      Next, schedule your reading. I challenged myself to read at least 30 minutes each day (even if I was exhausted on call) and 2 hours on weekends. Schedule this time and keep up. Mark off things as you go so that you can see some progress. Find a fellow resident and lecture/explain your readings to each other. Question each other so that when the in-service exams come around, you both will be prepared. Make yourself communicate with the resident that you have least in common with on your team. They are with you and you have to function as a team. I learned much from my fellow residents who were so generous with helping me as I helped them by taking extra call when needed and covering holidays for them when needed.

      Now I am learning to be generous with my spirit and my good will. I am very fortunate to be able to do what I do (something that I love) and to touch the lives that I can touch. I have learned to see the dignity and majesty in all human beings especially those who appear to have no voice but have so much to say to us and to give us. When I look back on those that I have lost, I am humbled by the losses but I know that I have more to do and to give. Good luck, my friend and take some time to refresh and renew yourself.

      Comment by drnjbmd | 25 July, 2015 | Reply

      • Thanks Dr. Dmjb. I’m trying to develop into a warm hearted person and regardless, nothing should affect my patient care. Best regards.

        Comment by Sandar | 26 July, 2015

      • To Sandar:
        Your motivation comes from within and not from any attending (or other persons) for that matter. Drop the word “should” and replace it with “will” as you see fit for your career. I promise you that when empathy takes place in one person, it affects all around them. Focus on connecting and listening to your patients; the rest will come. This is why medicine (and medical training) can be quite difficult. There is a need to seek affirmation from those around one, yet affirmation has to come from you. Forgive whatever performance you had in the past and use the very next minutes to revamp and renew. “Act as if ye have faith and to ye, faith will be given.”. That’s a line written by Aaron Sorkin who created “West Wing” but it essentially means “fake it until you get it.”. Best wishes-Drnjbmd

        Comment by drnjbmd | 28 July, 2015

  3. I’m really really sorry, for you and for them. Residency is so so hard. I hope that you are well and are seeking help for this too

    Comment by MrKnowBody | 10 July, 2015 | Reply

  4. Thank you so much for sharing this! I can tell that you care deeply about other humans and the work you do as well! As a future medical student I am not only blessed to see that there are people in the field that care a great amount but also proud to know that one day I will be joining this particular group! You are very much appreciated and I am praying for you, your colleagues and the young man’s family even more!

    Comment by Joyous | 3 July, 2015 | Reply

  5. Thank you for sharing this. I started my intern year today and I am preparing myself mentally, physically and intellectually for this journey. I know that maintaining balance may not be possible all the time but I will try hard to incorporate some introverted “me” time. I have started to wake up a few hours earlier before my shift to exercise, pray and self-reflect- even if it means I only have an hour of solitude. I think incorporating even 15-30 minutes of alone time to unwind can hopefully offset some stress and also making sure to keep in touch with loved ones. We will see how this plan goes after a few months into intern year!

    Comment by 7billiontravellers | 1 July, 2015 | Reply

    • To 7billiontravellers:
      Looking forward to your posts on your blog about your experiences. Take care of yourself and your colleagues.

      Comment by drnjbmd | 1 July, 2015 | Reply

  6. Thank you for writing this! It’s a very difficult situation for all involved. I’m glad that your residency program – especially being a surgery program – offers support.

    You might be interested to know that In Training (a blog of articles written and reviewed by med students) recently did a feature on mental health, depression, and suicide in medicine – http://in-training.org/tag/in-training-mental-health-week

    Comment by Anon | 1 July, 2015 | Reply

    • To Anon:
      Thank you for the link.

      Comment by drnjbmd | 1 July, 2015 | Reply

  7. Thank you for writing this. Unfortunately this topic has been getting a lot of coverage recently. If you haven’t already I invite you to read Pamela Wible’s article(s) on this topic: http://www.kevinmd.com/blog/2014/11/physician-suicide-101-secrets-lies-solutions.html

    As a 4th year medical student pursuing General Surgery and sitting on a sensitive committee at my school I have the opportunity to see the intersection between the stresses of the medical profession and “life”. There are unique realities that are pushed to their limits in residency, particularly intern year, that should warrant increased vigilance to these issues. Substance abused muddies the picture even more.

    I am happy to see that there are surgeons like yourself who are helping interns and providing this type of mentorship. Believe me that your efforts, even in light of this event, are not in vain. Student, interns, colleagues need your support.

    It’s a pity you can’t divulge which program you work for because students are looking for programs that do what you have described. Perhaps I can suggest that you write an post about how to find general surgery programs (or any specialty for that matter) that accomplish the balance between demanding excellence and offering a supportive environment for learning and ultimately flourishing as a physician. Thanks again for writing.

    Comment by qtipp | 1 July, 2015 | Reply

    • To qtipp:
      As I get about the country, more and more surgical faculty are beginning to listen to those of us who have been advocating for changing our methods of training. First, you have to come out of a program being a competent and safe surgeon with a strong medical knowledge base that will enable you to practice. Obtaining those things is not a crap shoot but compels those who are seeking good training programs to tell those behind them to apply here. This needs to be done by the “slam-dunk” candidates (AOA, strong USMLE scores) who will have many choices.

      I am also very encouraged that I have been able to collaborate with many people both inside and outside medical education that want their physicians/surgeons to be moral and honest human beings. Those qualities have to be in place before, during and after medical school. It is a gift from God that I am able to practice what I love and that I am able to touch the next generation. I find champions at the highest levels of surgical practice now because many of the old school surgeons have retired. Choose your programs wisely and listen to those who interviewed this past year. Good luck.

      Comment by drnjbmd | 1 July, 2015 | Reply

  8. This must have been a difficult story to write. Thank you for sharing.

    Comment by Malaika | 1 July, 2015 | Reply

    • To Malaika:
      Thank you so much for your kind words. This is still very difficult for me and has stayed with me for many months.

      Comment by drnjbmd | 1 July, 2015 | Reply

  9. Oh what a horrible tragedy, but sadly this does not surprise me at all. 😥

    Comment by Sweet mama | 30 June, 2015 | Reply

    • To Sweet mama,
      This surprised me completely. Our whole residency program is ultra-supportive because we understand the stress that training confers on newly-minted physicians. We offer many options for stress relief and pay very close attention to our residents. We have a very nurturing environment for them to learn and flourish. I believe substance abuse was part of this but not the entire part. I also believe that I have to keep vigilant and connected with those around me at all times.

      Comment by drnjbmd | 1 July, 2015 | Reply


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