Authors: Loice Swisher, MD (Drexel University College of Medicine), Ramin Tabatabai, MD (LAC +USC Medical Center), and Amy Ondeyka, MD (Inspira Health Network) submitted on behalf of Mental Health Task Force of the Resilience Committee
Starting residency is both exciting and terrifying. An intern plunges into the barely known with a whole new set of expectations, co-workers, and support system. To ease this stress, virtually all residencies have orientations and/or intern boot camps to bolster preparedness for this new role within the medical system. Human resources terms this process as ‘onboarding’. Onboarding orients new hires to the cultures, skills, and behaviors expected during employment. With increasing emphasis placed on the risk of resident suicidality and depression, resources for health and wellness are often highlighted in these sessions.
Less recognized as a risk, and perhaps even more stressful than starting residency, is the transition one makes after graduation to become an attending. As a new attending, one has ‘left the nest’, and is expected to make life and death decisions on their own, without the protective support system they have grown accustomed to in residency. In Joiner’s Theory of Suicide, two of the factors important to developing suicidal ideation are 1) a sense of isolation and 2) a sense of failure or being a burden1 . Residency itself may have some protective features as there is an entire cohort going through the same experience.
In a recent EM:RAP interview2, Mel Herbert reflected on a former resident (Tony) who died a year after graduation. He explained, “You go from residency where you see a great patient and you turn around and there are like five of your friends to talk about it, whereas in private practice you have to see the next patient and there are 20 more in the waiting room. A very different experience. For some people, that idea that you are captain of the ship, you’re in charge, it is all up to you, well, it makes you feels pretty good. But for some of us, it makes us feel a little lonely out there. The stresses are real. For some people, they become overwhelming.”
It seems we lost Tony when the safety net of residency was gone. This could happen to any graduating physician going out on his or her own. One might move to a new location, completely disrupting their support system. This transition may leave one’s doctor, therapist, or counselor behind as well. At the same time, the successful completion of training produces the highest feeling of self confidence in a graduating resident, who then may digress to feelings of an eroded sense of competence while adjusting to the new responsibilities of attendinghood. Compounding the problem may be ignorance, fear, or lack of time in accessing resources- especially mental health resources. How do we best help residents after they graduate? Perhaps one answer is better preparation before they graduate
On June 1, 2017, Dr. Thomas Nasca sent a letter3 introducing the concept of onboarding wellness during orientation of new interns. This letter provided several suggestions to develop and promote a culture of awareness and support. In a similar way, we have the opportunity to facilitate wellness awareness and support with a dedicated “off-boarding” to prepare our residents for graduation.
Offboarding can be discussed at any time, and possibly multiple times throughout training. The goal being to let residents know about the hardships they will likely face after graduation, to recap the wellness topics they have learned throughout the years, and to remember what resources will still be available to them post-graduation. A dedicated one on one session in the final training months provides an opportunity to respond to individual needs and concerns. The graduation dinner or celebration is another time that works well for an offboarding reminder. Residents will likely have family at these events that can absorb this important message and provide a reminder of this option if a difficult time does arise.
- Transitions are hard: Even for the “best and the brightest” these changes can be unexpectedly devastating. Compounding the stress of professional transitions, are the ever present and onerous life changes. Respect for overwhelming stresses and emotions during transitions must be highlighted.
- Tough Times Happen: Research shows that 90% of people encounter at least one traumatic event in their life6. Whether it is dealing with a toxic work environment, clashes with their chairperson, pending litigation, a tragic case, the devastating effects of mother nature, a mass shooting, or even stress with home and family life; difficult situations and life crises are almost certain to occur. Even if the particular circumstances are different, one is not alone in the experience. We all go through dark times.
- Develop a Resilience Plan: Since we should expect every one of our trainees to have a life crisis at some point, it is prudent to motivate our residents to develop a framework for their own resilience plan. It is possible to foster deeper resilience habits and ways of thinking before they are needed. The five pillars of resilience can be used as the framework in devising a personal plan7 . Another option is Charney’s Prescription for Resilience8.
- Connections are Critical: Relationships are an essential part of well-being and resilience. It is important to encourage the continuation of personal connections after transition points. Institutionally, the development of resident and faculty mentor families is one way that you can start a trust network that can continue after graduation. These families typically include one resident per training year and one faculty mentor. Each family can meet and talk as they please including in-person dinners, emails, or text chains depending on the situation. Having a mentor family that one can count on throughout all years of training should promote a sense in each resident that he or she has someone to call on, even after graduation.
- Know Your Resources: Remind them of available resources:
- Employee Assistance Program (EAP): Employee assistance programs are available to many emergency physicians through their hospital or contract group. EAPs provide a limited number of free, confidential counseling sessions.
- Hotlines: There are a variety of text, chat and phone crisis lines, which can be accessed by anyone 24/7/365. Some institutions have developed their own hotline systems.
- Physician Health Programs: Most states have a physician health program that may be able to help doctors dealing with addiction and by following their protocols may be able to keep their license and return to practice.
- Trusted Friends: Sometimes the issues that plague a person are relatively typical professional or personal stresses. Just being able to express those feelings to someone else may be significantly beneficial. It is worthwhile to have at least one or two trusted persons that you can vent to in times of need.
- Phone Home: As faculty, it is our job to ensure adequate training for our residents to become competent attending physicians upon graduation. We can also make it our job to instill in our residents that they will always have us in their corner. That support system never goes away. After all, who is better equipped to talk about these situations than an entrusted faculty mentor or designated wellness champion from residency? We can emphasize that we are still available to listen and provide guidance. We need to ensure that our residents know that they will never be a burden and can always call home.
Burnout, depression, addictions, and suicide are very real risks, and perhaps increasing risks, for our residents as they graduate. If we can do a better job with mental health and personal wellness training in residency, perhaps we can change the trajectory of the alarming statistics that our trainees currently face. Maybe we can give a future Tony or Carlos or Greg a different path to take. Conceivably we could save a life– and isn’t that the reason many of us went into emergency medicine in the first place?
- The interpersonal-pyschological theory of suicidal behavior: current empirical status. http://www.apa.org/science/about/psa/2009/06/sci-brief.aspx
- The dark side of EM. https://www.emrap.org/episode/burnout/burnout
- Nasca T, Physician wellbeing and graduate medical education (e-commmunication June 1, 2017)
- Oaklander M, Doctors on life support. http://time.com/4012840/doctors-on-life-support/
- The Lin session- resident wellness. https://www.emrap.org/episode/pneumoniainthe/linsession
- Morin A, Nine ways mentally strong people bounce back from crisis. http://motto.time.com/4295247/mentally-strong-crisis-bounce-back/
- The five pillars of resilience. http://www.bouncebackproject.org/five-pillars/
- Charney D, The resilience prescription. https://icahn.mssm.edu/files/ISMMS/Assets/Files/Resilience-Prescription-Promotion.pdf