More Resiliency is Not the Answer

Physician suicide has received greater attention due to an acute rise in rates during the COVID-19 pandemic. But this is not a new problem — physician suicide has been on the rise for 150+ years though it has remained medicine’s best kept secret until recently. Although more than one physician dies by suicide every day, institutions are only now facing criticism for their responses, or lack thereof, to this mental health crisis and their roles in perpetuating a culture of silence.7 Physicians are dying at a rate two times higher than the general public and suicide is now the #2 cause of death among resident physicians.1 This year, we will lose at least 400 physicians to suicide in the US—the equivalent of two full medical school classes.1 It was heartbreaking to learn that one of our own, in our community, had died by suicide—an intern only seven months into residency. I couldn’t help but to wonder what we—as a system and a community—had done to this young, driven resident to take away his will to live? Like many physicians practicing medicine for decades, one leader at our institution chose to question his resiliency. “[He] had a different idea of what medicine is and when he got here, he just couldn’t handle it,” he stated. It was clear—none of us were immune to this toxic culture and the silent epidemic. They believe the higher suicide rates are a result of millenials not being resilient enough, often citing their own experience in “surviving” harsher residency conditions with no duty hour policies. However, many fail to consider the higher patient volumes and greater complexity of medical management today as a result of advancements in medicine. Patients are older, sicker, and face far different complications than they once did. Medical protocols and documentation have become more time consuming than they once were. Although the practice of medicine has clearly evolved in recent decades, the culture has not. The culture of medicine has hinged on the principle that being exposed to greater stress builds better, more resilient physicians. However, research has shown that when humans are exposed to uncontrollable stress, they tend to give up and this response is maintained even when opportunities to escape that stress are presented to them later—a concept known as learned helplessness, which can render individuals vulnerable to mental illness in the future.2 Although duty hour rules were established to prevent medical errors made by overworked physicians, many programs violate these policies and continue to overwork residents. In fear of retribution by program administrators, residents often never report these violations and therefore, only some programs get cited for these violations. After the death of Dr. Deelshad Joomun in 2018 at Mt. Sinai St. Luke’s Hospital, one resident reported “her program had a resident meeting —not to address the death, but to discuss an upcoming survey by the ACGME [and] what they should and should not include on the surveys, advising them not to air their dirty laundry out in public.”3 Unfortunately, it is common practice for programs to coach residents on how to fill out these surveys—at times, justifying survey results by blaming poorly worded questions and misunderstandings. This results in the silent suffering of medical residents who are pressured to continue working in an abusive environment due to a state of learned helplessness. Prolonged exposure to this toxic environment can erode one’s resilience and mental health, too often leading to a tragic ending as it did in the case of Dr. Joomun. These silencing behaviors by residency programs reflect an unwillingness to acknowledge the systemic problems contributing to resident mental illness. Without acknowledgement by

institutions, it is impossible to create effective change — as seen by the increasing rates of resident depression and suicide. The data supports that medical trainees are at increased risk of depression with more than 28% of residents experiencing at least one major depressive episode, compared to 7-8% of the general population.1 Interestingly, studies have shown that after only four web-based cognitive behavior therapy sessions, suicidal ideation decreased by nearly 50% among interns. However, physicians who die by suicide are less likely to have received mental health treatment than non-physicians.6 In combination with the stigma of mental illness and long work hours, getting help can be daunting for medical residents.5 In an effort to acknowledge my role as a chief resident in addressing these barriers and prioritizing mental health, neurology residents were excused from work to attend free, confidential counseling sessions that were pre-scheduled by the Physicians Wellness Collaborative (PWC). I hope to inspire other programs to effectively use PWC’s resources by continuing to schedule multiple sessions throughout the year to ensure our residents have a provider they can feel comfortable calling during times of increased stress. Furthermore, I want to encourage an open dialogue to normalize seeking help. This year, the neurology and radiology residents and faculty came together to honor National Physician Suicide Awareness (NPSA) Day with a grand rounds lecture given by Dr. Michelle Chestovich, who lost her physician sister, Dr. Gretchen Butler, to suicide this year. By honoring this day annually, I hope to educate faculty, residents, students, and administrators at our institution. I am writing today to ask institutions to hold themselves accountable by joining us in making physician mental

It is time for institutions to acknowledge that more resiliency is not the answer, and a new approach involving systemic change is needed. Every life lost is one too many and we cannot afford to keep losing this battle.

health a priority and helping build a new culture of transparency to destigmatize depression, mental illness, and suicide.7 It is time for institutions to acknowledge that more resiliency is not the answer, and a new approach involving systemic change is needed. Every life lost is one too many and we cannot afford to keep losing this battle. For every physician and trainee reading this, I want to echo Dr. Chestovich’s words to you and your colleagues—do not let anyone tell you that you are not resilient, you are among the most resilient people out there. Remind your peers of this and please empower each other to take a stand and advocate for future generations of physicians—for our safety, our loved ones’ safety, and our patients’ safety.

Dr. Bindi Parikh is currently a chief resident in her 4th year of training at the University of Minnesota Neurology Residency Program. She plans to continue her training as a neurocritical care fellow at the University of Maryland, starting in July 2022. Dr. Parikh is dedicated to improving awareness of physician suicide and empowering institutions to make changes to help heal physicians.

Resources: 1. https://wichita.kumc.edu/Documents/wichita/ asa/NPSAfastfacts.pdf. 2. https://www.psychologytoday.com/us/blog/ the-other-side/201902/the-resilience-paradoxwhy-we-often-get-resilience-wrong. 3. https://www.refinery29.com/enus/2018/02/189624/mount-sinai-st-lukes-suicides. 4. https://payneresilience.com/blog/what-resilience-is-not. 5. https://nam.edu/addressing-burnout-depression-and-suicidal-ideation-in-the-osteopathic-profession-an-approach-that-spans-the-physician-life-cycle/. 6. https://www.acgme.org/globalassets/PDFs/tenfacts-about-physician-suicide.pdf. 7. https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC8170626/.