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What Is Resilience? - Insights on Residency Training Insights on Residency Training

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NEJM Journal Watch is happy to welcome a new panel of Chief Resident bloggers for the 2016-2017 academic year. Here’s a sample of what our new bloggers will be discussing, starting on August 1!

Jamie Riches, DO, is a 2016-17 Chief Resident in Medicine at Memorial Sloan Kettering Cancer Center

Jamie Riches, DO, is a 2016-17 Chief Resident in Medicine at Memorial Sloan Kettering Cancer Center.

Resilience” is defined as the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress.

On March 9, of this year, my colleagues (my friends) and I unclipped our pagers from our belts, scrub tops, and white coats to read, en masse, “Important announcement at noon conference today.”

At that noon conference, we found out that one of our fellow residents had committed suicide by jumping from the hospital housing building. This intelligent, dedicated, accomplished young physician was the third internal medicine resident in our 22 square mile city to perform this act with identical detail in just under 2 years. We were dismissed to return to our pagers.

We picked ourselves up, literally, from sobbing piles on the bathroom floor and answered our pages. The work did not stop.

March 9 calendarThroughout the following days and weeks, we were offered grief counseling sessions and open forums during noon conferences, where we could discuss our feelings and reactions. One morning, we were given free breakfast. We received many emails detailing these logistics, often ironically referred to as “housekeeping” items by the administration. We were desperately trying to clean up our own mess. The work did not stop.

After more than 3 weeks of waiting for the institutional silence to be broken, we were again called to an important noon conference. We were addressed by a senior physician lecturer. He spoke about depression and suicide, and how these things can often be inevitable, unpreventable. We were reminded that we are in a high-risk profession. A stack of handouts made its way around the auditorium, offering a prescription for resilience. We were advised to train ourselves to develop a positive attitude, to face our fears and find a resilient role model. This was followed by an anecdote, highlighting the speaker’s ability to receive terribly tragic news involving one of his family members and to walk directly into a patient’s room to resume work after hanging up the phone. The lecturer proceeded to present his research on resilience, largely based on studies involving military personnel and prisoners of war suffering from post-traumatic stress disorder. Correlations were made between entering the practice of medicine and entering the battlefield.

As the lecture proceeded, I began to realize that the traumatic event to which we were referring was not only our colleague’s suicide, it was our residency training. Unfortunately, this is not a correlation with which I am unfamiliar.

The forum was then open. “Please share your thoughts, experiences… and let us know: What can we do?” What can we do?

After a long pause, one of our most highly respected senior residents spoke, expressing his frustration with the fact that we were expected to resume work minutes after being informed of this tragic and shocking event. He stated that the perception of needing anything more than to take a deep breath and simply get back to work as equivalent to weakness, in combination with the “fear of retaliation,” was likely why no one was saying anything in this forum. This was followed by a reminder from our program director that “some people were given time off, and some people are still taking time off.”

This was true. One or two people had taken time off. We were not yet aware of what the repercussions of this time off would be. One month prior to this event, our chief residents had sent email to some of the senior residents: “If you are getting this email, it is because you have sick days to pay back. Sick days need to be paid back before June 30 so the program can sign off on your 3 years of GME, so please pick up shifts when you can.” Any resident who had taken a sick day in the past year was instructed to find time to cover an extra shift in order to “pay back” the institution for allowing recovery time. I had a flashback to another mass email referencing recent lateness to an outpatient clinic shift: “These instances are deplorable… You will become that person whom people hate to work with because of your lack of professionalism. Don’t turn into that, there’s already plenty of them plaguing our health system and we certainly don’t need any more.” These words were sent from those chosen to be our advocates. A wise, seasoned (and resilient) mentor of mine once gave me this piece of advice: “The institution will never love you back.”

Directional arrow sign postDespite these examples, I don’t consider my program malignant. Malignancy in residency training refers to those programs in which the residents are placed in a hostile working environment. Despite having rapid administrative turnover (four program directors and three medicine chairs in 3 years), we have administers who are generally open to addressing resident concerns and who attempt to make changes based on resident feedback. This larger issue is not institutional; it is systemic.

I pride myself on my resilience. I am a New Yorker. I watched the Twin Towers fall on September 11, 2001, knowing that my family members were inside, saving others’ lives and sacrificing their own. I shared the grievous guilt of every family member, not only acknowledging that it could have been me, but wishing it had been. When I was choosing my own career, my father sat me down at an old wooden table at Chumley’s Bar and asked me if I thought I was “too good for the fire department.” My fear of fire is one I chose not to face. During my first year as a physician, my intern year, I received a phone call from my mother’s husband, informing me that she was in the ICU, and it “didn’t look good.” My mother’s life was plagued by a series of self-inflicted illnesses, and its culmination was that of multiple organ failure and a series of failed and futile resuscitation efforts. When I got the phone call that “it was time,” I walked into one of my patient’s rooms and informed him and his family member that I would be gone from the hospital for the afternoon because I had something to take care of. The patient’s sister replied, “I’m sure you’re very busy and have plenty of things to do, but this is his life we’re talking about.” I’ve cried every time I’ve lost a patient, someone’s mother or beloved family member, ever since. I continue to reflect on my disappointment with the overwhelmingly accepted notion that our training — the apex of our years of education, the threshold of our careers as physicians — is a traumatic event unto itself. Although, I know, in some ways, this is inevitable.

We enter medicine as if we are walking into a sacred space: hallowed halls where hierarchical gods prevail and miracles happen… until they don’t. We spent thousands of hours staring at computers and making phone calls and answering seemingly incessant pages, attempting to address questions to which we may not know the answers. We struggle to balance quality of care with quantity of care. We carry the underlying responsibility for the most vulnerable, most intimate moments of many people’s lives. This can feel like both a blessing and a burden. We not only carry people’s lives in our hands, we feel responsible for their deaths. We are tested every single day. Our knowledge, our patience, our compassion, our skill, our determination, and our stamina need to be demonstrated, examined, and verified. We struggle to find ways to work within a system that often feels punitive for its own faults. It can be lonely. It can be exhausting. It can be traumatic.

The Intern Health Study, a longitudinal study of depression among interns nationwide, estimated that “suicide rates among physicians are something like 40 to 70 percent higher in males and 130 to 300 percent higher in women.” Statistical estimates state that as many as 400 physicians commit suicide every year. Three young men and women leapt to their deaths in one city, in 16 months. We are not experiencing a tragic event; we are experiencing a harrowing trend. What can we do?

“Our needs are our greatest assets. I’ve learned to give everything I need.” – Andrew Solomon

The quote above is from a TED talk that, for months, I watched almost daily during my commute. This quote and many others gave me a great sense of comfort when I was grieving, tired, lonely, insecure, and burnt out. Looking back on those words, I wonder if the sentiment itself, or my attachment to it, is a reflection of the pathological need of the physician to feel strong.

I stood up to speak, not yet aware that my emotional state was one in which anything less than an [administrative] offer to turn back time would be received as an insult.

The resilience lecture began to feel less therapeutic [albeit well-intentioned] and more like a venue for perpetuation and exacerbation of a culture that was in itself, the compressive stress. We were being trained like soldiers, in the wake of our fallen comrade, to go out and fight! Be strong! Our strength was being measured by our ability to silently struggle through whatever we were experiencing and get the job done. Admit. Discharge. Admit again. We were being given tools to obviate the natural human state of vulnerability. We were “tasking victims with the burden of prevention.” We were reminded to be proud of our ability to charge on. I ended my commentary by stating that we were using the language of an abusive relationship.

What can we do?

  1. Eliminate the word “burnout” from the lexicon: Not only does burnout minimize the severity of depression, detachment and (at extremis) suicidal ideation among healthcare professionals (HCPs), it implies that those suffering post-trauma have some inherent flaw or weakness that impairs their ability to remain functional. This mindset removes the onus from the system.
  2. End the stigma: Remove the question, “Have you ever sought treatment for any mental illness” from the job applications. We should encourage residents, physicians at all levels, and other HCPs to actively seek out cognitive therapy as we do vaccines or PPDs.
  3. Decide what graduate education is: If residents are primarily learners, we must protect their time and use it solely for educational (both clinical and didactic) purposes and not to provide underpaid labor to perform all tasks for which the hospital is at a loss, no matter how menial. If residents are employees, we must provide adequate pay for educational level, protect sick leave, and outline contractual responsibilities before enrolling in the agreement.
  4. Stop penalizing unwellness: Physicians and HCPs are as human as our patients. We are not immune to everything. There will be times when we will be ill, physically and emotionally. We will need time and space to heal.
  5. Structure the system in a way that minimizes fear of retaliation: If the person creating or enforcing destructive policies is the same person who needs to write the words “excellent candidate” on the letter of recommendation that carries the weight of your future career opportunities, your best and worst interests are one and the same.
  6. Embrace our own fallibility: Learn to be comfortable with imperfection. Let us have an equal respect for our accomplishments and failures. Employ mentors who set this example.
  7. Accept that medicine is not martyrdom: The work does not stop. Let it not deplete us. Let us take care of each other and ourselves and not give away everything that we need.

“Recover” is the key word in the definition of resilience. Physicians are intimately acquainted with the process of recovery; recovery is a process. I do believe we will recover from this event, although not quite restored to our original state. We can work together to implement changes to not only create, but demand an educational and professional environment of safety, wellbeing, and, ultimately, resilience.

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skorgu
1 day ago
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satadru
2 days ago
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New York, NY
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Allegedly Drunk United Airlines Pilots Arrested Before Flight To Newark

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Allegedly Drunk United Airlines Pilots Arrested Before Flight To Newark A United Airlines flight bound for Newark was in the process of boarding at Scotland's Glasgow Airport on Saturday when both the pilot and copilot were arrested on suspicion of being drunk. Carlos Licona, 45, and Paul (Brady) Grebenc, 35, are expected to be arraigned today in Glasgow for violating Britain's transport safety laws. [ more › ]
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skorgu
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I mean I don't like to go to EWR sober either so I can empathize.
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adulthoodisokay: thehoneyedmoon: uss-edsall: While sailing in...

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adulthoodisokay:

thehoneyedmoon:

uss-edsall:

While sailing in the Mediterranean sea, in 1962, the American aircraft carrier USS Independence (CV-62) flashed the Italian Amerigo Vespucci with light signal asking «Who are you?», the full rigged ship answered «Training ship Amerigo Vespucci, Italian Navy». The US ship replied «You are the most beautiful ship in the world».

Great, now I ship actual ships.

this makes me want to cry

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skorgu
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satadru
2 days ago
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New York, NY
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By geoff. in "Choose Your Poison... I mean, Sugary Cereal" on MeFi

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Oh god, I use to have to create websites for things like this. I can't even visit them without think of the horror on all levels: deadlines overpromised, big egos trying to get on big accounts, up late making sure a hastily, new late requirement is working. Delivering the code to ANOTHER third party IT company that actually deploys the code to the servers. Having them sit on it for two months after you killed yourself getting out. Some 23 year old account girl who always has a fucking starbucks cup in her hand promoting herself for some bullshit internal corporate award.

Getting an emergency call at 9PM because EAMER isn't reporting Chocula votes. Getting on a phone call about it, me trying to explain to a third party IT company that this possibly can't be a code problem but if they ship us the logs I'D BE HAPPY TO HELP BECAUSE THAT'S OUR MOTTO. Because they're also trying to win work from large multinational, they make an assy comment about "another code problem," and now my boss' boss wants to know when it will be resolved because 23 year old account girl is worried we didn't do it right, and then I explain well we had no QA because you guys tried to underbid, and we had no requirements and everything is kind of half assed and I shipped code at 3 AM who knows if it worked.

But no one cares and there's the poor 26 year old who just got his big job out of being an entry bot and he thinks this is all exciting, because he's making enough money for the first time and there's pretty girls and advertising campaigns are sexy and we're up all night launching big things and it looks exciting I guess, and he's trying to figure out what could be wrong and you look at the logs finally that got FTP'd to you (but still require a VPN that doesn't quite work), and you notice that one of their servers are down and last time this happened no one did anything until you "fixed the code" and then you decide that no one cares who wins, you're tired, everyone is panicking and all you need to do is make sure you keep the email addresses, just make sure those get registered, so you take all you work add a random vote count so the vote LOOKS like its registering because that's better then it not registering or even taking time to fix it and no one will care because no one looks at these things to make sure if they actually work. So you do that and its a change in code so it means that third party IT company will actually deploy it, which you're fairly sure will bump the server causing the issue (which is the real problem but it is sometimes easier to just do this then convince them they need to just take the node out of the cluster and restart it). And it works but now you have a new project on a tighter deadline, and are burdened with meetings where we have to lie about what we did to fix it, and how to "make sure we don't repeat the Cereal Election problems again," but politically we can't say what happened or why it happened and know the best course out of this is to make something up so you don't have three more meetings on your calendar that say "Cereal Election Triage Meeting." And you just got an email that the prototype you made for a Fruit Loops campaign two years ago is down and you ask how did that get into production, it was a prototype, and you find out that someone liked it and thought it worked so just use that to save money.

I HATE YOU PRESIDENT CHOCULA
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skorgu
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Matthew Garrett: Priorities in security

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I read this tweet a couple of weeks ago:

and it got me thinking. Security research is often derided as unnecessary stunt hacking, proving insecurity in things that are sufficiently niche or in ways that involve sufficient effort that the realistic probability of any individual being targeted is near zero. Fixing these issues is basically defending you against nation states (who (a) probably don't care, and (b) will probably just find some other way) and, uh, security researchers (who (a) probably don't care, and (b) see (a)).

Unfortunately, this may be insufficient. As basically anyone who's spent any time anywhere near the security industry will testify, many security researchers are not the nicest people. Some of them will end up as abusive partners, and they'll have both the ability and desire to keep track of their partners and ex-partners. As designers and implementers, we owe it to these people to make software as secure as we can rather than assuming that a certain level of adversary is unstoppable. "Can a state-level actor break this" may be something we can legitimately write off. "Can a security expert continue reading their ex-partner's email" shouldn't be.

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subbes
2 days ago
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SF Bay Area
skorgu
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1 public comment
kleer001
4 days ago
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Truth. Also I feel bad because I never thought of this. But it retrospect it's obvious.

Brooklyn Alamo Drafthouse Opening Delayed Indefinitely

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Brooklyn Alamo Drafthouse Opening Delayed Indefinitely What do we know about the Alamo Drafthouse coming to Downtown Brooklyn? We know it will be the first location of the famed movie theater chain in New York City. We know it will serve flatbread pizza, spiced lamb and more. We know they sponsored a screening of the original Star Wars trilogy to help hype their imminent arrival. What don't we know about the Alamo Drafthouse coming to Downtown Brooklyn? When it will open. Do they know? Ah, according to a statement the theater put out yesterday, they don't. [ more › ]
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skorgu
5 days ago
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RAAAAGE
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