I feel like I have to comment on here in light of the recent two suicides by medical interns in New York.
I feel like a medical intern committing suicide is one of those things that is shockingly sad. These are people who are so young, who worked so hard to be where they are, yet are so miserable that they are willing to end their life rather than face another day. As an attending who has a family and a good lifestyle, it's hard not to think, "How could they possibly do this?"
But at the same time, my intern year is not so long ago that I don't remember.
I was someone who was particularly miserable. I had worked really hard to be where I was, I did have a support system in that I was married, but I was still desperately depressed. I genuinely wished that a car would hit me on the way to work so that I wouldn't have to face another day of my internship. I don't think I ever had a call where I didn't feel like crying at least a few times. In fact, during at least 50% of my calls, I would go home and immediately burst into tears.
Why was I so depressed?
For starters, I worked with a couple of residents who were particularly nasty to me. But even when I had a really nice resident and coworkers, I was still unhappy. I didn't want to be at work in the middle of the night. I wanted to be home with my family. And treating sick patients, some of whom were dying, made it all that much harder and made me wish to be with my family even more.
On top of that, nothing I was doing felt incredibly important. It felt like everything I did involved following some sort of formula and not really thinking at all. If a patient had a symptom, you do the appropriate test, and treated the way the textbook told you to. It felt like a machine could do it just as well. It felt pointless. And the patients didn't seem at all grateful to us. (This probably wasn't made better by the fact that I was at a county hospital where a large percentage of the patients didn't speak English, were homeless, or drug addicts.)
But the crazy thing is, nobody knew.
Aside from my family, nobody at work had any inkling how miserable I was. I know this, because when I made the decision to leave my program (my alternative to suicide), my program director told me he had checked with my previous residents and attendings and asked them about me, and they all thought I seemed completely fine. So either I was really great at hiding my emotions, or every single intern was completely miserable, so we all basically seemed about the same.
So what can be done to keep tragedies like these suicides from happening again?
Well, I don't really know. But whatever they're doing now completely stinks. Despite the fact that all of us interns were under so much stress and pressure, nobody bothered to check in on our mental health at any time. During residency we had some sort of discussion group with a psychiatrist that we all went to, but that was useless and got canceled half the time anyway.
Maybe every program should be required to hire a good therapist to check in with all residents a few times a month and make sure they are doing all right. Maybe there should be worse consequences (or just consequences at all) for residents and attendings who are cruel to underlings. Maybe there should be more interns in every program, so if you gets sick and need a day off, you don't feel like everyone in the program hates you. (I will never forgive my co-intern who sent me a nasty email while I was having a threatened miscarriage for missing a few hours of a call.)
Even if most interns don't end up pulling the trigger, we don't want a bunch of suicidal interns responsible for patients' lives. I really think this is an issue that needs to be addressed seriously, but in the end, I sort of doubt anything will change.
It's all about the human connection, isn't it? Treating patients that you can connect with in a positive way gives you a boost, as does working alongside other medical staff who are friendly and pleasant. I've rotated through hospitals with good and neutral environments, and I've also seen programs that were so toxic that I don't think people would believe stories written about them. It's not hard to see how someone could become suicidal in such a program.
ReplyDeleteI don't know that medicine is unique in the issue of how to deal with suicide and depression. Don't we always reach the same conclusion; that people should be more open to those around them, and don't be afraid to reach out if they feel that someone might be suffering? I think the only surprise point is that it doesn't happen more often in medicine. Medicine is ideally populated by caring, compassionate people, and yet the work hours and demands induce a lot of stress. Nobody functions well under stress, and even the most caring and compassionate among us can be warped (at least temporarily) by it.
I don't know what can be done to change it, though. Unless they are toxic to a ridiculous level (and make a lot of other errors), no resident or physician is going to be fired from a program for being nasty to others. I haven't seen many programs that have such a number of personnel that the workload could easily be absorbed by those who remain, and senior physicians aren't easily replaceable (not yet, at least).
I think Medicine is unique in this regard, mostly because The suicidal interns are actually responsible for lives, and also because the amount of debt incurred by interns makes simply leaving the job impossible.
DeleteThis is the best thing you have ever written here on this blog, and I hope that it is really widely read and discussed. Good work.
ReplyDeleteThanks. It is an issue close to my heart, because of what I went through during my own internship. And also because of all I know I would've missed out on if I had done what these interns did.
DeleteDid you ever have suicidal ideation when you were an intern?
DeleteLedgem, your final paragraph above is what I think the problem actually is. There seems to be a widespread belief that nothing much can be done about it, and that the way things are is the only way. How about these ideas?
ReplyDelete- have an effective 360 degree feedback system which is taken seriously and that has consequences
- reduce working hours to a sensible level. Sure you'll need to employ more staff but they'll claim less overtime too.
- more effective collective action from junior doctors, which should be regarded as a sign of initiative and proactivity rather than avoided for fear of rocking the boat
In short I believe that the field of medicine has been hijacked and held hostage by the old school who refuse to admit the possibility of change and are prepared to exploit their subordinates to maintain the status quo.
We recently had an intern commit suicide at our hospital- a different department than the one I work in, but no less upsetting.
ReplyDeleteWhen I was an intern, I definitely had passive suicidal ideation. No active plan to do myself harm, but definitely wishes of being hit by a train as I drove to work. Later in residency when I talked to my friends, many of them endorsed similar feelings. I don't think it's just about having malignant seniors and attendings and nurses. It's also from a feeling of futility - of never being able to know enough or do enough, that maybe I would never be a good enough physician. Combine that with severe sleep deprivation, and it's a dangerous situation.
I think mandatory therapist check ins, along more flexibility for mental health days, would go a long way.
I'm not in the medical profession, so maybe my own thoughts about this aren't worth much. (I stumbled across your blog a year or two ago and come back because it's interesting.)
ReplyDeleteI really think that there needs to be a greater change at the institutional level, particularly in terms of leadership: that the people in charge need to recognize that a key part of training healthcare providers includes training them to treat each other well in the workplace and to care for themselves effectively in general. It's not just a matter of check-ins-- it's a matter of defining and enforcing what kinds of behavior won't be tolerated and it's also a matter of saying that there are times when caring for yourself has to be on the front burner, this is how to do it, and here's how the institution will promote it.
I think that medicine has a funny relationship with healthy behaviors sometimes: we know that there are so many negative effects associated with sleep deprivation, we know that, hello, using the bathroom is a biological need... yet medical training and even the way that medicine is practiced relies upon you ignoring those sorts of things and pushing beyond what's reasonable. It doesn't seem right that the people who get the most training on how to take care of the human body, including the human brain, are simultaneously taught to ignore chunks of it as it applies to themselves.
All very well said. I also had a lot of mostly passive suicidal ideation during my intern year. Never felt that way while doing the avalanche of in-hospital work (largely thanks to my day-brightening interactions with patients and positive feedback from attendings regarding my job performance), but I had plenty of chances to think about how miserable I was during my commute to and from the hospital. I gave every ounce of my energy plus energy I didn't think I had to that job, so at the end of the day I had nothing left and not enough energy to replenish what I'd lost.
ReplyDeleteI got through it in large part by pep-talking myself to just put one foot in front of the other and giving myself permission to quit at any time (advice from a wise mentor who hated his first job and malignant boss). It didn't give me a healthy outlook, but at least I made it through.
No one ever knew how I felt. They all thought I was too perky to be depressed. I later learned that many interns (and residents) feel similarly. I had a friend who sought counseling during intern year. It impacted her ability to get disability insurance later. Trainees (and all docs, really) are really discouraged from seeking outside help, so sometimes suicide is the first sign of a problem.
Also notable that the suicides occurred in August, so close to the start of internship. In July and August it is very hard for most interns to see any light at the end of the tunnel. A countdown clock helped me. When I hit the 10% mark, I decided "I can do 9 more of those." During the worst times, I remembered that every 3.65 days done represented another percentage done.
ReplyDeleteBut living in such a way that I prayed for the days to pass quickly was a terrible way to live. I appreciated my good fortune as I cared for so many ill and unlucky people. But I felt guilty that I did not appreciate or enjoy the gift of my life more than I did. I would never go back and do it again.
One of the interns that committed suicide was a friend and medical school classmate of mine. He suffered from bipolar depression on top of which he was trying to adjust to the stresses of intern year and moving to the big city from quite a small city. I think the more important issue in addition to better monitoring the mental health of residents is to end the stigma of mental health in general so that people feel more open to talking about mental health issues. Even many doctors are guilty of perpetuating the stigma by not taking time to ensure both the physical AND mental health of their patients. The death of my friend is incredibly tragic, as he was incredibly brilliant and had a special way of inspiring his classmates. I can only hope that he is now at peace and that his death serves as a reminder of how real of a disease mental health really is.
ReplyDeleteI'm sorry for your lose. May he rest in peace.
DeleteAnonymous in California. My husband works at a tech start-up where they have a full-time in house psychologist. Everyone is mandated to have a session once every three months, but she's really good, and a lot of the employees talk to her weekly. The mandated sessions are free, and she charges a minimal fee for sessions on top of that.
ReplyDeleteBeing treated like a real person is huge. Also when one person is unhappy, it can be contagious. Oh, and then there's the not having any control over your life, and having to take it in the ass repeatedly with a smile on your face. FOR NO REASON. But I digress.
ReplyDeleteThank you, Fizzy, and thank you all for posting. Katherine, you described my own experience and feelings,particularly the sense of futility and the fear of inadequacy for the responsibility. Fortunately for me, on my worst day my senior resident asked me how I was doing, then kept asking until I stopped lying. He then took over 30 minutes, at the end of his own 14 hour day, to listen and give me some good advice. Among other things, he told me "You have to get paid. Whatever it is that makes medicine worth doing for you, you have to find a way to experience some of that on a regular basis, or you will burn out and quit."
ReplyDeleteMy cointerns, like those of anonymous 10:42, were surprised to hear that I considered eating a gun more days than not.
Fizzy - thank you so much for this article.
ReplyDeleteI'm a medical student in my final year of clerkship and some days I find the stress and exhaustion to be overwhelming. For me, the feeling of starting a new job - in which you are scrutinized and evaluated on a daily basis - once every 6 weeks is so very stressful.
Also, the threat of a bad or even mediocre evaluation card is enough to make me tolerate bad treatment by residents. For some reason, the culture of "paying forward" the misery is still alive in some specialties - surgery seems the worst - and the status quo is for residents to make clerks feel like glorified secretaries/servants, simply because it was done to them first.
I have never been so ashamed than to see a profession that is supposed to be about caring be so heartless towards their own. Think about what is telegraphed to patients? If you treat your own this way, what do you think of us? I do things for my good docs, because they deserve it. They look out for me, and I look out for them.
ReplyDeleteGreat post Fizzy. Lots of empathy I've been there. Mainly in fellowship with toddler and baby and marriage not working and trying to stay on top of it all. I too was able to project a pulled together image to the world while I was falling apart. I see it's not unique. I follow Pam Wible on Kevin M.D. - read many letters of suicidal physicians falling apart and leaving the profession in disillusionment. I'm happier now - hope you are too. There's got to be a solution. Maybe I'm too much of a Pollyanna for having hope. But I still do. It's a broken system. I hope we can fix it a little bit in our lifetime.
ReplyDeleteThanks for the post. I liked it. As an IMG, having done another residency before, and now being in my second residency in North Amercia, I have thought about suicide many times.Our nasty, malignat seniors and attendings humiliated me and discriminated me many times but I am still alive and continue! I am both older from average residents and more suceptible to sleep deprivation but still continue. I am happy your shared this thought.
ReplyDeleteHey, thanks Anon above. IMG here. I was ridiculed for my difference in my training (like not knowing when to laugh when some actrors/shows/etc were mentioned. Then I also sustaned some cruel remarks spitted in my face due to my background. But in my experience when training ends, you are respected for what you are. I enjoy status of top professional in my group, lecture peers about best practices, am active in national organizations. I feel on top of the world now. I am sad for people who were cruel to me, because I find it hard to believe they are happy now. Then again, maybe they were so burnt out themselves. Hand in there, the best part is after residency.
ReplyDeleteI'm an intern in the other part of the world, and i have that feeling too, hoping i'd just fall sick, wishing my appendix ruptures or something so that i won't have to be at the hospital facing some retards superiors who couldn't even detect an obvious ICB (drowsy trauma patient who kept on vomitting) but still ridicule my every suggestion. Only that, in this part of the world, if we intern ever complained of depressed (some of us committed suicide too, some became crazy beyond return, some just went mia and never return), our superiors will ridicule us even more, starting their sentences with "during our time we suffer more but not end up like you."
ReplyDeleteI guess it's just the fate for interns all over the world...I love medicine, but the training is just inhumane. Not sure how long i can endure it.
I attempted suicide as a senior resident. I'd been depressed all through my residency (and thought about it all the time) but by third year I had run out of coping mechanisms. I kept thinking things would get better as I got to be the senior but they didn't- I just had attendings yelling at me for things I did AND things my interns did. I also didn't exercise, drank too much, and slept all the time I wasn't at the hospital so I had no social life. I was married but between working all the time and sleeping all the rest of the time that didn't help much.
ReplyDeleteI think the biggest thing was that I felt like a fraud, like I'd done well in college and med school because I tested well, and I really wasn't good enough to be a doctor. I felt that I'd be an incompetent attending, but I'd gone too far in medicine that I couldn't do anything else (not so much because of debt, but because being a doctor was so much a part of who I was), so the only solution was to kill myself.
Needless to say it didn't work, and I was fortunate enough that my husband didn't figure it out and take me to the hospital, so I don't have a "record" (I had been on antidepressants briefly in college and 1st year med school and that already limited my ability to get disability insurance, as someone above had said). I don't know what got me through the rest of the year other than that I was now out of pills and didn't have the guts to buy a gun.
But eventually it got better. I got a good job (NOT in the horrible ICU), started living healthier, moved to the country, and had some kids. I am not a horrible doctor, though I still feel like a fraud sometimes- although apparently the CEO of Yahoo does too so at least I'm in decent company. My mood is good most of the time, I cry maybe 3-4x/year instead of 3-4x/day. Honestly, the hardest thing that I have to deal with now is that for so long I had suicide as a "plan B", that even 10 years later I have trouble taking it off the list, even though most of the time my mood is pretty good.
And other than anonymous internet comments, I don't really talk about this. Mostly because I don't want this to be the thing people think of when they think of me, but also because I know that if I told my story one of the easy lessons it would teach is that you'll have fewer resident suicides if you keep people with a psych history out of med school.
Thank you so much for sharing your story. As somebody pointed out below, excluding anyone with the mental health background would probably result in an even worse shortage of physicians than we have now.
DeleteAs a premed, med student, intern and resident you've been conditioned to be hard on yourself. It's unfortunate. Let me let you in on a little secret.
DeleteEveryone feels like a fraud. Freud fainted several times in Jung's presence.
"I was fortunate enough that my husband didn't figure it out and take me to the hospital, so I don't have a "record" (I had been on antidepressants briefly in college and 1st year med school and that already limited my ability to get disability insurance, as someone above had said)."
DeleteThis.^ This is the reason docs with mental health issues don't seek help. We are just never allowed to need outside assistance of any kind. We're taught to act as though everything is fine at all times, but we would never advise patients to cope in this manner. It's unrealistic to think that an individual, no matter how well adjusted, will never need outside support during particularly tough times.
As a podiatry extern, I had a front row seat to this madness. I, myself, was
Deleteexempt from it all. Reading these posts, I'm filled with a terrible sense of
sadness. Perhaps hospitals need to institute an intern/resident advocate
to deal with all theses issues.
Hospitals usually (always?) make an off-site therapist available to residents. But there is a strong culture of fear & uncertainty among physicians that their efforts to seek help will be used against them later and impact employment or work environment. The message is that we should suck it up and fix any problems on our own (as our attendings before us presumably did) regardless of what health-promoting resources may be available to us. For this reason, I personally would have avoided using these resources had I needed them during residency.
DeleteAbove -- THANK YOU for commenting. It can't have been easy to write, or to experience. I have not attempted but have thought about it. I have tried to talk to my interns and students about mental health in medical training in a ge delete thatneral way. Hoping these publicized suicides give us permission to be more open. (And if you excluded everyone with mental health concerns from medical training, you'd probably have very few doctors.)
ReplyDeleteThat was supposed to say "a more general way." My phone is acting up.
ReplyDeleteI just finished my intern year in one of the most prestigious institutions in the world for one of the most competitive specialties in medicine. And it was MISERABLE. So far second year hasn't been much better. If I do a great job, I get no recognition or appreciation. If I screw up, I get eaten alive and berated as a human being. If I ever talk about trying to have a life outside of medicine, my attendings and co-residents turn on me. Anyone who hasn't thought of suicide in residency is either lying or in derm. I'm over medicine - this isn't what I signed up for.
ReplyDeleteI am not an MD so I say this with total objectivity. As opposed to the UK,
Deletethere is no royalty in the USA, except for physicians. I hope that offers
some comfort. Please don't lose your humanity.
I feel this way, and I just finished my sub-internship. Thanks for the post--now I don't feel so alone in my sentiments.
ReplyDeleteQuestions for the physician: Is it possible to survive the medical school experience with your humanity intact? Secondly, knowing what you know now, would you
ReplyDeletestill take the same path?
Yes, you can survive with your humanity intact, but you see situations differently from how you saw them before medical training. New information changes a worldview.
DeleteNo, I would not take the same path. Finished my training and am considering quitting. Whenever passive suicidal ideation crossed my mind during internship, I reminded myself that I always had the option of quitting. I do regret gaining all this training that I can hardly use to help people. Most of my time is spend entering data to meet government requirements and documenting the visit details to limit my risk of getting sued (or at least protect me if I do get sued).
I have access to so much more useful knowledge than our current system allows me to use. Too often I'm forced to accept whatever the insurance company or patient is willing to cover rather than the ideal treatment and/or diagnostic test. I also lament not being able to spend more time educating patients, as teaching others to help themselves is my very favorite thing to do. Not sure if there's any profession that would allow me to do this, tho' (even teachers have to spend too much energy maintaining order and teaching to the standardized tests...).
A few months ago I purchased a laptop with Windows 7 (my older computer with
ReplyDeleteWindows XP was no longer being supported.) The gal I purchased it from
gave me detailed information regarding the new system. It's important to
periodically unplug your computer to allow the battery to drain, she informed me.
For if you don't, she added, and allow the battery to run at 100% capacity all
the time, it will burn out. Words to live by.
This will probably get missed, but best place for me to vent right now. I just started intern year and did an oncology rotation. I had a cancer patient for recurrence of neck cancer. He asked for a burger, but I made him NPO and put an NG tube in. After he could eat again he asked again for a burger but we told him to take it easy at the beginning and I sent him to rehab. Two days ago I ran into his wife in the ED and she told me he passes away while in rehab and never got to eat that burger. I've been daydreaming about quitting every day since.
ReplyDeleteNot missed. This is a great, thought-provoking post and people will be reading it for a long while. You did the best you could within the limits of our current system. We're not allowed to give oral food to people who are going to aspirate (unless they do it against medical advice). The reality is that he probably would have eaten no more than a few bites of the burger. Maybe he would have aspirated and died of pneumonia, and I'm not sure that would have been the worst thing, but as a physician you're not allowed to sign off on that if you care to keep your license. On the other hand, food often sounds better to the dying patient than it actually tastes, so maybe the fantasy of the burger was actually a good thing in his last days. You did your best.
DeleteI don't know if you've seen this, but it really helped me: http://edwinleap.com/malpractice-and-suicide-july-emn-column/
ReplyDelete