Authors: Angela Carrick, DO (Norman Regional Hospital) and Angela Chen, MD (Icahn School of Medicine at Mount Sinai)

---

Each June our new intern classes show up bright-eyed and bushy tailed ready to jump into training in emergency medicine.  They understand residency will be both exhilarating and exhausting.  Some move to town with their spouse or family in the area, yet others have no support system except their co-residents and faculty.  The residents attend a comprehensive two-week orientation and learn hospital policies, how to use Meditech®, and our program requirements from the handbook.  Two entire days are spent undergoing necessary certifications in life support so that each one of them could resuscitate a patient in cardiopulmonary arrest.  It would seem they learned the ins and outs of what to expect in their next four years of training.  They were set for success and ready to jump into action July 1st and save some lives!  

We were teaching our excited new physicians in crisp white coats vital instructions on how to care for patients, however our orientation had a glaring gap.   We provided no information on how they should take care of themselves. What steps should a resident take if they found themselves in a state of anxiety, depression or even having suicidal thoughts?  The subject matters of depression, anxiety and suicide have not been part of the traditional preparation for residency nor have they even been “normal” topics of discussion at work, likely because there is a stigma associated with disclosing these feelings.  Physicians are seen as tough, having weathered years of grueling training and there is a real fear of being perceived as weak or needing help.

Unfortunately, not speaking about these issues does not mean that anxiety, depression and suicide are not prevalent amongst doctors.  The shocking reality of our profession is that an estimated 300 physicians die by suicide in the U.S. per year.¹  Suicide is the second leading cause of death in resident physicians.² Over the past few years this astounding reality has been brought to light. As physicians who serve as role models and educators, It is our duty to broach these difficult conversations with our residents and teach them the risks of our profession and tools to manage these struggles.   

Integrating these topics into the orientation agenda was a brand new concept for our program yet makes perfect sense.  Interns, compared to all other years of residency, are at the highest risk for suicide.  The greatest proportion of resident deaths by suicide happen during the PGY1 year.²  The start of the academic year (July through September) is the highest risk time during the entire residency training for this to occur.²  This is likely due to the stress of transitioning from medical school to residency. Introducing these topics to interns early also has an added advantage of normalizing this conversation surrounding these important but stigmatized issues.

We have to “prophylactically” teach our entire class of interns about their risks of depression and suicide as well as give them tools to help manage these crises should they arise.  Even residents without any previous risks or history of mental illness may develop depression or thoughts of suicide during residency.  They are thrust into a stressful, high-stakes environment combined with sleep deprivation, financial hardship and little time for self-care.  

According to well-known psychologist and suicide expert Thomas Joiner there are three pieces that together lead to suicide attempts.³  One initially develops a desire for suicide by possessing “perceived burdensomeness” (the feeling you are a burden on others) and a “thwarted belongingness” (feeling you are not accepted by others).³ Third and finally, you must acquire the capability for suicide. This happens over time when a person can become desensitized from fearing death. Upon reflection, we found that these scenarios can all arise during residency, even for residents who enter training with no previous history of depression or suicidal ideation For residents, an example of perceived burdensomeness may be an error at work causing difficulty for their attending and patient.  A resident may feel thwarted belongingness due to isolation away from their family or the inability to find a social circle. The third component of the theory of suicide, desensitization to death can happen to an emergency physician who sees death regularly at work and also learns the most lethal means of death through studying toxicology and trauma.

As leaders of these residents we must teach them to put a plan of action in place before any of these issues ever develop, because chances are high that they will.  The prevalence of depression among resident physicians range from 21% up to 43%.⁴ One preventative means to provide our residents is a safety plan.  This plan originated in the psychiatry field as a brief intervention used with suicidal patients in the emergency department.  It includes a stepwise list of coping strategies and sources of support that can be used to alleviate an emotional or suicidal crisis.⁵  The user writes down coping strategies to help them recover in case of crisis as well as people to call for help.  

Dr. Angela Chen, Emergency Medicine Physician, proved safety plans are adaptable and highly utilized by emergency medicine interns. While completing the CORD Mini-Fellowship in Wellness Leadership she studied utilization of safety plans at her hospital and found 81% of interns felt a safety plan would help them manage a crisis. Within the first three months of their intern year, almost a third of the intern class had utilized their plans.

I presented Dr. Chen’s plan to my own interns the past two years as part of an orientation “wellness lunch.”  We sat down and talked about the rigors of residency, how common it is to develop depression and the possibility of even feeling suicidal.  I disclosed my own difficulties as an intern, including utilizing counseling, and mentioned it was normal to have these types of feelings.  Although it is a challenging topic to discuss, just getting it out in the open helps rid of the stigma associated with these mental states.  I encourage every program to include this as part of orientation and give this tool to all of your residents.  A sample safety plan document is below for use. 

References:

1.Center,C., Davis,M., Detre,T., Ford,D.E., Hansbrough,W., Hendin,H., Laszlo,J., Litts,D.A., Mann,J., Mansky,P.A., Michels,R., Miles,S.H., Proujansky,R., Reynolds, C.F. 3rd, Silverman,M.M.(2003). Confronting Depression and Suicide in Physicians. JAMA, 289(23), 3161. doi:10.1001/jama.289.23.3161

2.  Yaghmour, N., et al.  “Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment.”  Academic Medicine: July 2017-Vol. 92, Issue 7-pg 976-983.

3.  https://en.wikipedia.org/wiki/Interpersonal_theory_of_suicide

4.  Mata M.D., D.  “Prevalence of Depression and Depressive Symptoms Among Resident Physicians.” JAMA. 2015; 314 (22): 2373-2383.

5.  Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract 2012 May;19(2):256-264.

 

Sample Safety Plan:

Personal Crisis Management Plan

Step 1.  Warning Signs (thoughts, images, mood, situation, behavior) that a crisis is developing: 

1. 

2

3. 

Step 2.  Internal Coping strategies—things I can do to take my mind off my problems without contacting another person (relaxation techniques, physical activity) 

1. 

2. 

3.

Step 3:  People and social settings that provide distraction:

1. Name & Phone                                                                          
2. Name & Phone                                                                        
3. Place 
4. Place

Step 4:  People whom I can ask for help:

1. Name & Phone
2. Name & Phone
3. Name & Phone

Step 5:  Professionals or agencies I can contact during a crisis:  

**Suicide Prevention Lifeline Phone:  1-800-273-TALK (8255)**

1. Primary Care Clinician Name & Phone
2. Psychiatry/Counseling/Psychologist Clinician Name & Phone 
3. Hospital Employee Assistance Program 

Phone # (Available 24/7).  6 free sessions per year.

Step 6:  Making the environment safe

1.

2.