Are programs to blame for resident suicides?

[Thanatos]

Came across this on social media today......he was a PGY4 general surgery resident who lost his life to suicide a few days ago and this was posted by his spouse. Certainly I feel like this topic comes up often, the number of physicians who kill themselves is staggering. The most quoted statistic I see is the equivalent of a medical school class a year....which seems like a lot.

We all know people who struggled with training and the demands it places on all of us.....I've always maintained surgery residents are quite resilient. Sometimes I wonder if its this expectation though that adds to the problem. I can't say I ever contemplated suicide.....homicide on the other hand I still consider on a regular basis (probably more often than I should admit). But maybe that's just a facet of my personality.

As a new attending I'm in charge of teaching our most junior residents, and certainly they seem like a happy group of hard working people. They have all the concerns anybody would have.....they want to be well trained and capable, they want to succeed in their careers. And while they clearly have some anxiety about that as best I can tell they seem reasonably content. Based on all the unnecessary abuse I took during residency my plan is to be part of the solution going forward, and not to carry on any culture of that abuse that I may have experienced. Teaching them takes up a lot of my time, but I have to admit it always makes me happy. If any of them ever came to me with some mental/psychiatric concerns I have to admit it would certainly get my complete attention.....and I would refer them to whoever they needed asap. I'm not the most touchy-feely person you've ever met and obviously I'm not a mental health professional....but I would make damn sure they got the help they needed.

Suicide in our field is concerning. But what I find most disturbing about that post is what she says in between the lines....."I don't care what your program tells you or what your attending tells you, if you need help...." "nobody thinks you aren't capable of doing your job just because you don't feel comfortable with certain tasks." In another post I didn't copy she says "encourage them to ask for help no matter what, even if their program frowns upon it." Jesus. I'm sure she's grieving and maybe she holds them responsible....but I get the impression there's more to this story. Did this guy ask to get help and they blew it off? That's troubling to say the least.....then again we all experienced things in training that would be consistent with that sort of attitude.

I asked around the shop today and turns out we have a whole protocol for this....they have people available to help like 24/7 which seems like a good idea. Interested in what the rest of you have seen and done. I don't have any solutions to this problem, other than not to make things any worse and try to get people the help they need.....I can't even fathom just blowing off a depressed resident or colleague. Seems like this guys program may have dropped the ball....

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[dpmd]

I don't know. I think ultimately the only "blame" that can be placed is on the person who attempts or succeeds (though their illness is really what is at fault). You can't force anyone to get help and sometimes even with help it will still happen. If you want to place blame on the program then you also need to blame the wife who obviously is a lot closer to the guy than anyone at the program, and blame the co-residents who didn't intervene even though they spend a lot of time with the guy. Doesn't that sound ridiculously simplistic and kinda rude? Not to say that any of those folks can't in fact have done wrong things, but I don't think placing the responsibility on others is the right answer.

 

[mikeGR]

Most programs I would imagine don't have designated protocols and people available to help 24/7. I would also imagine that some of the people who need help do not have easy access to it, i.e. locating a therapist/psychiatrist on their own who is covered by their insurance but not within the same hospital system etc. Last, not sure if true, but in the past I heard that if you seek such help you need to declare it to the medical board when you apply for licensing later and that may cause further hesitation in asking for help.

 

[operaman]

I feel like there must be more to this story as well. Hard to say if the program dropped the ball or something else happened entirely.

We too have a rather robust system for mental health care for residents and about 20% of house staff utilize them in some way during their training. I think this is fairly standard now at most places.

I have a hard time with these situations because throughout medical school and a surgical residency I haven’t once encountered anything remotely approaching what I would consider abusive. It’s actually been a lot of fun! There have been hard days but nothing insurmountable and generally on par with hard days in my last career. So I have a hard time empathizing with people who say training is brutal and abusive because that simply hasn’t been anything like my experience. Maybe I just got lucky or am blissfully unaware of how bad I have it.

Based on my n of 1, I’m inclined to think the onus is on the individual to see to their own mental health the same way they have to see to their own hypertension or diabetes or obesity or whatever. My other unpopular opinion is that schools and residency programs may need to screen harder for mental illness in applicants and direct those applicants into parts of the profession less likely to push them beyond their ability to cope. How to do this obviously requires care and study, but I think it would do more to save lives than mindfulness and drum circles.

 

[armybound]

I think resident mental health is important. As surgeons I think there has been an attitude of toughness and a lack of willingness to help. "Call me if you need me, but don't need me." This can't continue.

 

[dienekes88]

View attachment 281473


Came across this on social media today......he was a PGY4 general surgery resident who lost his life to suicide a few days ago and this was posted by his spouse. Certainly I feel like this topic comes up often, the number of physicians who kill themselves is staggering. The most quoted statistic I see is the equivalent of a medical school class a year....which seems like a lot.

We all know people who struggled with training and the demands it places on all of us.....I've always maintained surgery residents are quite resilient. Sometimes I wonder if its this expectation though that adds to the problem. I can't say I ever contemplated suicide.....homicide on the other hand I still consider on a regular basis (probably more often than I should admit). But maybe that's just a facet of my personality.

As a new attending I'm in charge of teaching our most junior residents, and certainly they seem like a happy group of hard working people. They have all the concerns anybody would have.....they want to be well trained and capable, they want to succeed in their careers. And while they clearly have some anxiety about that as best I can tell they seem reasonably content. Based on all the unnecessary abuse I took during residency my plan is to be part of the solution going forward, and not to carry on any culture of that abuse that I may have experienced. Teaching them takes up a lot of my time, but I have to admit it always makes me happy. If any of them ever came to me with some mental/psychiatric concerns I have to admit it would certainly get my complete attention.....and I would refer them to whoever they needed asap. I'm not the most touchy-feely person you've ever met and obviously I'm not a mental health professional....but I would make damn sure they got the help they needed.

Suicide in our field is concerning. But what I find most disturbing about that post is what she says in between the lines....."I don't care what your program tells you or what your attending tells you, if you need help...." "nobody thinks you aren't capable of doing your job just because you don't feel comfortable with certain tasks." In another post I didn't copy she says "encourage them to ask for help no matter what, even if their program frowns upon it." Jesus. I'm sure she's grieving and maybe she holds them responsible....but I get the impression there's more to this story. Did this guy ask to get help and they blew it off? That's troubling to say the least.....then again we all experienced things in training that would be consistent with that sort of attitude.

I asked around the shop today and turns out we have a whole protocol for this....they have people available to help like 24/7 which seems like a good idea. Interested in what the rest of you have seen and done. I don't have any solutions to this problem, other than not to make things any worse and try to get people the help they need.....I can't even fathom just blowing off a depressed resident or colleague. Seems like this guys program may have dropped the ball....

Everytime there's another physician suicide, I think it's a systems issue.

I don't think we can peg it on any one individual. It's no doubt some combination of the individual, the work environment, the home environment. To the susceptible mind, it just takes the wrong milieu to put someone in the wrong place.

I don't know. I think ultimately the only "blame" that can be placed is on the person who attempts or succeeds (though their illness is really what is at fault). You can't force anyone to get help and sometimes even with help it will still happen. If you want to place blame on the program then you also need to blame the wife who obviously is a lot closer to the guy than anyone at the program, and blame the co-residents who didn't intervene even though they spend a lot of time with the guy. Doesn't that sound ridiculously simplistic and kinda rude? Not to say that any of those folks can't in fact have done wrong things, but I don't think placing the responsibility on others is the right answer.

It does seem a bit rude to cast blame on his wife and co-residents, but we can't completely blame the one person who attempts/succeeds since isn't that a version of victim blaming? Maybe in the right environment he could've succeeded.

Success and failure can rarely be pinned on an individual. If a person fails, it seems to me that the environment has to play a part.

I feel like there must be more to this story as well. Hard to say if the program dropped the ball or something else happened entirely.

We too have a rather robust system for mental health care for residents and about 20% of house staff utilize them in some way during their training. I think this is fairly standard now at most places.

I have a hard time with these situations because throughout medical school and a surgical residency I haven’t once encountered anything remotely approaching what I would consider abusive. It’s actually been a lot of fun! There have been hard days but nothing insurmountable and generally on par with hard days in my last career. So I have a hard time empathizing with people who say training is brutal and abusive because that simply hasn’t been anything like my experience. Maybe I just got lucky or am blissfully unaware of how bad I have it.

Based on my n of 1, I’m inclined to think the onus is on the individual to see to their own mental health the same way they have to see to their own hypertension or diabetes or obesity or whatever. My other unpopular opinion is that schools and residency programs may need to screen harder for mental illness in applicants and direct those applicants into parts of the profession less likely to push them beyond their ability to cope. How to do this obviously requires care and study, but I think it would do more to save lives than mindfulness and drum circles.

I imagine it's tough. I have all these medical students come through on my service some of whom have subsequently matched at my program. I can't tell who is going to do well and who is going to struggle. I imagine figuring out who's going to become depressed is even harder.

With respect to your inability to empathize, I would encourage you to look beyond your own experience. Part of your ability to get through this is resilience. Part of it is your luck. There are people who truly do have to train in objectively abusive and brutal training environments, and I'd encourage you to count your blessings.

 

[dpmd]

Everytime there's another physician suicide, I think it's a systems issue.

I don't think we can peg it on any one individual. It's no doubt some combination of the individual, the work environment, the home environment. To the susceptible mind, it just takes the wrong milieu to put someone in the wrong place.



It does seem a bit rude to cast blame on his wife and co-residents, but we can't completely blame the one person who attempts/succeeds since isn't that a version of victim blaming? Maybe in the right environment he could've succeeded.

Success and failure can rarely be pinned on an individual. If a person fails, it seems to me that the environment has to play a part.

I put blame in quotes because it really ultimately is their illness to blame rather than something under the control of the individual. But they have more control over a suicide attempt than any single other individual or any combination of individuals or environmental milieu. Blaming the program or the wife or the co residents is a different form of victim blaming because the successful attempt leaves a number of people in a position to be affected by it. I find it all very distasteful to play the blame game. I am all for people trying to enact policies that in general are meant to be helpful or at least not hurtful, but to treat it as a deficiency in the individuals or the collective environment in the absence of a defined improper action taken is wrong to me.

 

[operaman]

Everytime there's another physician suicide, I think it's a systems issue.

I don't think we can peg it on any one individual. It's no doubt some combination of the individual, the work environment, the home environment. To the susceptible mind, it just takes the wrong milieu to put someone in the wrong place.



It does seem a bit rude to cast blame on his wife and co-residents, but we can't completely blame the one person who attempts/succeeds since isn't that a version of victim blaming? Maybe in the right environment he could've succeeded.

Success and failure can rarely be pinned on an individual. If a person fails, it seems to me that the environment has to play a part.



I imagine it's tough. I have all these medical students come through on my service some of whom have subsequently matched at my program. I can't tell who is going to do well and who is going to struggle. I imagine figuring out who's going to become depressed is even harder.

With respect to your inability to empathize, I would encourage you to look beyond your own experience. Part of your ability to get through this is resilience. Part of it is your luck. There are people who truly do have to train in objectively abusive and brutal training environments, and I'd encourage you to count your blessings.

I agree I’ve been very lucky. And while I believe that many people struggle and that there are some truly awful situations out there, i still find it challenging since my experience has been soooooo devoid of anything abusive. Maybe if I’d had one bad rotation or one awful attending in Med school or a bad rotation as a resident I could at least extrapolate and say it’s a systemic problem, but I didn’t. I’ve definitely encountered my share of a-holes but no more or less than in my prior career.

I just see so much rhetoric in the press and on social media calling it moral injury or human right abuse or some such thing and I just can’t make the mental leap from my world of unicorn farts to something so inhumane. And while I can imagine there are isolated pockets of terribleness, I can’t believe a system wide moral injury and culture of abuse would somehow pass me by entirely after so many years immersed in it.

I don’t mean to devalue others’ experiences. I wonder if people who had similarly good experiences are less apt to speak out, leaving a terrible selection bias in the prevailing zeitgeist

 

[mikeGR]

I don’t mean to devalue others’ experiences. I wonder if people who had similarly good experiences are less apt to speak out, leaving a terrible selection bias in the prevailing zeitgeist

I would imagine it's harder for people who have had actual problems to speak up, rather than for people who have had a good experience. Speaking about your emotional/psychological/other problems can come at a personal/professional price, especially for surgeons.

In residency we had about one resident in each class that suffered some type of issue. It is a very complex issue, a combination of the individual and their personal circle, the institution, and the profession. There are countless stories of extreme examples, i.e. suicides. I agree that happy-ending stories should also be heard, but this doesn't take away the fact that there is a systemic problem that needs attention. People who don't recognize that problem due to different personal experiences may not be the best fit to deal with it.

 

[dienekes88]

I put blame in quotes because it really ultimately is their illness to blame rather than something under the control of the individual. But they have more control over a suicide attempt than any single other individual or any combination of individuals or environmental milieu. Blaming the program or the wife or the co residents is a different form of victim blaming because the successful attempt leaves a number of people in a position to be affected by it. I find it all very distasteful to play the blame game. I am all for people trying to enact policies that in general are meant to be helpful or at least not hurtful, but to treat it as a deficiency in the individuals or the collective environment in the absence of a defined improper action taken is wrong to me.

Perhaps.

In an individualist world, we are all pulling ourselves up by our bootstraps, and this is one version of the American dream. It seems unfair for someone who is keeping it on the straight and narrow to have to take on the challenges of someone else's personal maladaption to some potentially malignant environment.

I can't even pretend that I got to where I am on my own. My family, my mentors, my colleagues and friends... I am forever in debted to them. As one of the senior guys now in my program, it's partly on me to help get the folks around me across the finish line. Having said that. You can bring a horse to water, but you can't make it drink, so I try not to get too annoyed when I watch my colleagues squander opportunities.

I agree I’ve been very lucky. And while I believe that many people struggle and that there are some truly awful situations out there, i still find it challenging since my experience has been soooooo devoid of anything abusive. Maybe if I’d had one bad rotation or one awful attending in Med school or a bad rotation as a resident I could at least extrapolate and say it’s a systemic problem, but I didn’t. I’ve definitely encountered my share of a-holes but no more or less than in my prior career.

I just see so much rhetoric in the press and on social media calling it moral injury or human right abuse or some such thing and I just can’t make the mental leap from my world of unicorn farts to something so inhumane. And while I can imagine there are isolated pockets of terribleness, I can’t believe a system wide moral injury and culture of abuse would somehow pass me by entirely after so many years immersed in it.

I don’t mean to devalue others’ experiences. I wonder if people who had similarly good experiences are less apt to speak out, leaving a terrible selection bias in the prevailing zeitgeist

I'm happy for you.

 

[deleted941485]

Medicine has the uncanny ability to psychologically torture their young. More so than any other professional group out there and with utterly devastating consequences.

These so called teachers prey on neophyte relatively idealistic and sometimes foolish interns and resdients many of who are in debt, are in tenuous relationships, and probably have some sort of inferiority complex mixed with an underlying depression. You mix in ****ty hours, passive aggressive nonsense, getting **** on by seniors, and having your career dangled in front of you by your superiors

Many people being selected for this training and being fed into this system are prone to suicidal tendencies (their sens eof self worth is tied up in this nonsense likely) and the system is designed to take these people and push them to either succeed or jump off a ****ing bridge.

the system was designed by masochists and I think the whole metal health movement in medicine has made things worse for at risk residents because now they are going to be labeled as weak and unable to get through and these depts dont want to have a suicide on their hands so they quitely try to get rid of them. Theyll still commit suicide but just not while they are employed by them.

A world of wonder awaits you!

 

[wholeheartedly]

I don’t know if it’s possible to screen better. I thought I’d read about studies showing that people going into medical school have about the same rate of depression etc as the general population, but those numbers are quite different coming out of training.

 

[Thanatos]

Certainly an interesting topic and I'm glad we can generate some discussion....like many of you I'm naturally inclined to think of this as a personal responsibility issue. I think it jives well with how we're trained and probably how many of us think already.....hell everyone in this line of work is a little ****ed up, and if you weren't when you started you definitely were at the end. We all went through it and you just had to find your way.

That being said I don't know......there's something about this situation that bothers me. I remember being perpetually annoyed as a general surgery resident that anything that went the slightest bit wrong was explicitly my fault....and I do mean everything. Clinic running late....damn residents. Patient not in the room on time....well back in my day when I worked for Dr. Famous Attending Jr we had everything perfect by 7:15am sharp!! If you did a toenail clipping on a 95yo morbidly obese diabetic guy with an A1C of 30 and there was a wound infection you would get excoriated at M&M if you didn't fall on the sword and take responsibility for the complication. I remember getting rocked at conference once as a chief because I had a patient that left AMA....he got in a fight with his floor nurse over something (while I was in the OR) and just bailed despite my interns best efforts. He showed back up a week later with AKI and a wound infection, and my attendings were literally beside themselves at M&M. "So Dr. Thanatos....when you decided to drastically fail in the care of this patient, were you thinking about his children growing up without a father? Or did you not take an adequate enough social history to know he had children, you monster and obvious total failure of a resident. We collectively weep for the future of our profession" And etc, etc....needless to say this these events were not isolated, nor specific to me. Roughly half the residents in the program failed the ABSITE a few years in a row and it was the same story.....damn lazy residents.

So I've spent more than a few years wondering, just in general, what are the responsibilities of the program anyway? Why is it when someone tanks the board or can't operate, it's their own personal failure?? There was something "wrong" with like half the people I trained with in one way or another if you talked to the program leadership.....again I'm not a psychologist but it didn't take long to trace all roads back to Rome. I guess what I'm trying to say is that it didn't take me long to start asking (dangerous) questions about the commonality of the many, many failings of the residents around me. When people quit....well they couldn't hack it you know, wasn't meant to be. They'll be happier as a radiologist anyway right, hahaha, wouldn't we all? But how often do we look back at the source and wonder....if half your residents are failing maybe it's the system?

And that's just my experience...but globally when you have a lot of people killing themselves in a particular line of work don't you have to wonder just a little bit? I agree with some of you above...it does seem unsavory to point the finger at any one particular entity. That being said I think about how in general programs blame the resident for everything and somehow that's okay...we call it "responsibility" and say it's requisite to becoming a surgeon and a professional. Unless it goes badly of course, and then its on the individual.....doesn't always add up I think.

In any individual situation there's probably enough blame to go around, but I'm hesitant to blame the victim or the family. It's encouraging that it sounds like many of our programs have these resources....whether people feel free to use them or not is obviously a complex issue. I found it interesting the comment above that up to 20% of residents are using these resources.....I think that's good and all but damn does that seem high to anyone else? And that's in the face of the fact that many state boards will flat out ask you if you're seeking mental health.....what would it be if there was no stigma?

I do agree that we tend to hear or at least fixate on more extreme examples of good and bad....I can only speak from my own perspective, but I trained for a long time in several places (residency plus fellowships) and think I can comment on these extremes: I was treated poorly as a resident but very well as a fellow (in brutally hard specialties in different locations). So I like to say I've seen it all, even though I"m only one person sharing my own heavily biased views on all things.

We don't know the specifics of this particular case, and I'm proud to say I'm in a place where the residents are well supported by me and my partners. I can imagine however, working in a culture where that is not the case.....and I can easily picture a scenario where someone would seek help and have it be denied, told to suck it up and get back to work. It may have cost this guy his life, or at least was a factor...I'm willing to bet some of you can picture that culture as well....easily.

 

[DoctwoB]

The reality is that surgical training is a major stressor even under the best of circumstances. The long hours, lack of sleep, feelings of inadequacy, guilt from complications, etc. take their toll on everyone. And all this is true even at the most benign program. Add on malignant attending behavior and it all gets worse.

So is a program to “blame”? That’s overly reductive. Suicide is the end result of mental illness, which itself is a combination of personal, genetic, and environmental factors. But can it contribute to a setting that leads to suicide? Of course.

IMO we need to approach it as we do M and Ms. complications are often multifactorial as, well, with patient, surgeon, and system factors. We focus on the factors that we can control and strive to improve. The same attitude should hold towards improving the mental health of residents, even if depression and suicide isn’t the programs “fault” per se.