The documentary “Do No Harm,” explores the national suicide crisis among physicians, who kill themselves at a rate twice the national average.
Many of these physicians are young (under 40), a significant percentage of whom are in their first or second year of training. The movie focuses on the unrealistic work hours expected of residents, the often highly competitive
nature of their programs, and their immense fear of making mistakes that
can be serious, even fatal. Combine this with their lack of sleep, exercise and healthy eating, and concerns over what is often crushing financial debt (which, on average, exceeds $200,000) and it’s easy to see the kind of stressors that typically face these young men and women – not to mention the additional challenge of facing a pandemic like Covid-19.
One recent study shows that only half of depressed interns obtain mental
health services. Their reasons include lack of time, lack of confidentiality, a
desire to manage their mental health independently, and professional stigma. Nearly half of those in the study believe their colleagues would have less confidence in them as medical providers if they sought psychiatric treatment.
A Dark Picture
While this situation may be painting an unnaturally gloomy picture, resident program directors and chief residents at SBH are taking a closer look at the health and wellbeing of their residents.
Grand Rounds now are regularly hosted on such topics as Wellbeing (as was
a recent presentation hosted by the Department of Pediatrics). During the Covid pandemic, the emergency medicine department conducted weekly webinars for residents led by individuals with psychological training and touching on such subjects as Stress, Anxiety and Uncertainty, Strategies During Covid and The New Normal and How to Transition Back.
“As doctors, we spend so much time learning how to practice medicine but
just as important is focusing on breaking down barriers of communications, improving interpersonal relationships, learning to connect with people better, and dealing better with emotions,” says Dr. Joshua Schwarzbaum, an attending in emergency medicine who ran the program with Dr. Joel Warden, an ethics consultant and theologian.
A series of institutional-wide surveys of residents was recently conducted as well, the most recent of which asked residents their feelings about the creation of a physical resident well-being center (which was overwhelmingly supported). The resident well-being committee has been expanded to monthly rather than quarterly meetings, and the number of events like retreats, picnics and other bonding events, though difficult to schedule because of conflicting schedules, has increased.
A nutritional program has been discussed. In addition to including medical nutritional modules from Tulane University’s teaching kitchen, program discussions have been held with Chef Emily Schlag, who worked
at the New Orleans school and is now the director of the soon-to-open Center for Culinary Medicine and Teaching Kitchen at SBH.
“Not only would cooking classes help teach residents to take better care of themselves, but it would be a bonding experience and a chance to share cultures. And, hopefully, it would also translate into taking better care of our patients,” says Dr. Victoria Bengualid, resident program director for the
Department of Medicine at SBH. “It can be a means to opening up the pressure cooker and letting the steam out.”
Physician leaders like Dr. Bengualid and Dr. Lizica Troneci, chair of the Department of Psychiatry at SBH, see the importance of a more global approach to supporting Residency Wellbeing.
“From my perspective as a physician, psychiatrist, resident program director, and department administrator, there is so much discussion around resident and faculty wellbeing and what must be done,” says Dr. Troneci. “One important approach is to teach residents resiliency. The health care system has changed so much since I was a resident. The amount of work, the bureaucracy, the challenges are greater than what I had. We didn’t have all these billing and regulatory requirements. I would hand write my notes on a patient in five minutes and an attending would come and add a signature. I didn’t have to deal with the EMR, which is built for billing and regulatory requirements and which leaves less time for interactions with patients. The communication is rushed and dismissive. Gone are the days of
the treatment team’s gathering by the nursing station, sharing charts and
Dr. Bengualid says recent improvements in the IT environment, which is an
initiative presently being pursued by the resident wellbeing committee, would make a huge difference in just, “narrowing the number of clicks from five to three.” Her residency program is unique in that it attracts residents from all over the world – representing 31 countries in 2019, as depicted in a past cover of this magazine. Foreign medical grads, she believes, tend to be more resilient than American grads – although no existing literature presently exists on foreign medical grads doing
residencies in American hospitals – if simply because they’ve often gone
through much more to get here. Yet, they too, she and Dr. Troneci agree, are
rarely prepared for the type of patient complexity they treat in the Bronx.
“As physicians, we have to ask questions that are traditionally asked by social workers,” says Dr. Troneci. “Is the patient homeless? Does the patient eat regularly? Is there an underlying psychiatric illness? And, in addition to being immersed in a very challenging, highly dysfunctional health system, our residents are often separated from family, have cultural and language issues, may have Visa issues, and so have buckets of stress.” This, she says, can be difficult at the best of times.
“If you come from one country and learned x, y and z and suddenly they
speak a different language and you’re told by the attendings that’s not how it’s done here and you should know this, or that’s not what it means here, that can be very isolating,” says Dr. Tina Wexler, chief resident in the Department of Medicine.
This can be particularly difficult when a resident suffers a personal crisis
that involves a family member living thousands of miles away. Residents who have reached out to Dr. Wexler for help have mentioned how different this is. “They have to be at work and often don’t even have the option of returning home, and they feel they can’t perform well,” she says. “They don’t want to be perceived as individuals who can’t handle the situation.” She suggested one such resident informally meet with Dr. Tina Krishnarao, her counterpart in the Department of Psychiatry. Fortunately, this resident got the help he needed, and graduated in June.
“It was heart wrenching to hear his story,” says Dr. Wexler, who knows something about the difficulties of residency from personal experience. She is one of the few American-born residents in the medicine program, having attended medical school in Israel – which is also very different than here, she says.
Dr. Wexler developed epilepsy while in medical school, and found out that
when she started her residency at SBH her seizures were not well controlled. “Neurologists say don’t be stressed and get a lot of sleep. That’s just not going to happen in residency,” she says. “I had some seizures at work and it was a very public, very impairing illness. It was pretty hard for me and I felt very isolated. I felt like I was the weakest link in the chain.”
According to Dr. Krishnarao, a separate resident wellness center would provide young doctors in training with the chance to see a psychologist in confidence. Such a center, she says, would support the wellness of residents
and medical school students by reducing psychological distress while enhancing mental health, well-being and quality of life. ”It would be confidential, with no records involved,” says Dr. Krishnarao. It would be such a place, adds Dr. Wexler, “where someone looks you in the eye and
there’s no judging. That’s an important step to take.”