You can’t step away from your EpicCare EMR platform for long these days before overhearing…
Like many others, I was distressed by the story of two resident physicians who died by suicide in quick succession in New York City this summer. Pranay Sinha’s September 5th piece in the New York Times, “Why Do Doctors Commit Suicide?” (http://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html?_r=0) brought critical attention to the alarmingly high rates of physician suicide. As he says, a culture of stoicism that fosters emotional isolation, and the alternately terrifying and exhilarating responsibilities of caring for patients, must surely contribute to depression in training and to physicians’ disproportionately high rates of suicide.
This is the heart of Dr. Sinha’s critique of the Osler’s classic recommendation that physicians practice equanimity: steadiness in tense situations. Sinha suggests this old idea keeps physicians isolated and opaque to one another. The concept of equanimity may seem antiquated – certainly no one in my training talked explicitly about this as a virtue – but its tenet of quiet control persists, for instance in our expectation that physicians be slightly aloof from the emotionality of the illness experience (1). We may also see the ideal of equanimity in the recent emphasis on civility in medical settings. A civil and respectful workplace has been shown to improve morale and lessen burnout. As a result, many medical centers have developed civility trainings and workshops (2). But if interpreted too strictly, civility can feel like a demand for polite behavior – for an outward show of equanimity — no matter the intensity of the situation. It can become yet another injunction against noticing, feeling, and expressing one’s inner experience. Again, a physician in distress could ask herself, how can I admit that I am in trouble when I am supposed to be “holding the fort”?
Unfortunately Dr. Sinha’s discussion of suicide focused on the experience of medical training rather than on the challenge of the physician role more generally. Dr. Sinha’s depiction of training as a time of intense hardship and hope conveys the strongly held beliefs in apprenticeship and hierarchy that are foundational to medical culture (3). Moving stories like his of idealistic young doctors enduring the physical and emotional rigors of residency are a genre unto themselves in medical writing (4). They can teach important lessons about the hidden curriculum of callousness, expediency, and objectification — toward patients and toward one’s colleagues — that can be morally corrosive and psychologically destructive.
Yet simultaneously, the power of the idea of apprenticeship in medicine can lead us to focus inordinate attention on the “apprentices” and forget the “masters.” For instance, the apprenticeship orientation has meant that action to support physician self-care often focuses on trainees. Curricula, social activities, support groups, buddy systems, and other approaches are increasingly made available during residency. But attendings sometimes stand on the sidelines for these curricula, as if, like their clinical skills, they long ago mastered these skills, too. Many medical schools offer multifaceted psychological support services for trainees while leaving attending physicians to go it alone when trying to find psychiatric or psychological support. Yet data suggest that mid-career physicians may be at highest risk for suicide, burnout, and isolation (5). The challenges for attending physicians facing depression can be even more substantial, given the perceived threats to reputation and career status that can accompany emotional distress.
A fundamental shift in medical culture would mean that camaraderie, reflection, self-care, and emotional growth become skills that physicians learn and re-learn together throughout their careers. Seeing attending physicians model these skills can have a profound impact on young physicians — equally so, to see attending physicians struggle with and get better at these same skills. Seeing the mastery as well as the practice are critical components of any good apprenticeship.
1. See for instance Robert Klitzman (2008) When Doctors Become Patients. Oxford University Press.
2. Heather Spence Laschinger, Michael P. Leiter, Arla Day, Debra Gilin (2009) Workplace empowerment, incivility, and burnout: impact on staff nurse recruitment and retention outcomes. Journal of Nursing Management 17(3): 302-311.
3. Joanna Veazey Brooks & Charles L. Bosk. “Remaking surgical socialization: Work hour restrictions, rites of passage and occupational identity,” Social Science & Medicine 75 (2012): 1625-1632.
4. Emily R. Transue (2004) On Call: A Doctor’s Days and Nights in Residency. New York: St. Martin’s Griffin.
5. Alexandra Sowa McPartland, in a recent blog in the Atlantic, “Suicide and the Young Physician,” (http://www.theatlantic.com/health/archive/2014/09/suicide-and-the-young-physician/380253) seems to make this same mistake of selectively reading data to theorize suicide as a problem of younger physicians, when in fact data indicate suicide risk is elevated throughout age cohorts but increasing in middle age cohorts most dramatically.