By Meaghan P. Ruddy
Paying attention to the wider trends in medical education recently makes it difficult to miss the growing voice of Pamela Wible, MD and her crusade to end physician, resident and medical student suicides. One premise of her argument is that all the language around burnout and resilience misses the point. The point it misses? This demographic is suffering from abuse.
I tend to agree. To this I would add that the result is not burnout but the closely related state of grief…
The book is far from closed on the causes of the depressive states that lead to suicide. As someone who personally struggles with dysthmia, major depressive episodes and suicidality, something that that has helped me to grow through the pain is the idea that depression can be thought of as grief over loss. There is as much a plurality over what people feel they have lost as there are people who lose things. That being said, the smaller the subculture, the more similar the experiences, the more similar the losses.
Think more personal than the loss of patients, which happens and is very troubling. The sorts of loss we speak of now are loss of self, loss of identity, loss of motivation, loss of so much that once mattered so much. Medical students, pressured into attempting to master ever expanding curricula can lose the confidence in their ability to learn and think, the very talents got them into the situation in which they feel so lost. This loss then expands to the people they may never help, the life they may never get to lead because the competition is so stiff for so few spots in the place they want so badly to be: residency.
Residents are pressured into clinical activities they did not learn in medical school. They quickly realize a lot of the things they agonized over for four years will never be useful to them and that they are expected to be able to do all the things they were never taught, or never bothered to learn because they were not on a high-stakes test. They see their seniors and attendings engaging in behaviors they would not think of engaging in and soon it is 2.5 years later and they are those same seniors. The only thing that keeps them going is the thought that soon they will be licensed and able to practice as they see fit.
But now, physicians are not practicing as they see fit. MOC, MACRA, EHRs impinge on practice and now more medical students than ever are working in teams and having to report to a board. The independence, the ability to care for patients without work-after-clinic, the prestige once promised all are gone. And to boot? An internet culture that seems to distrust the medical profession more and more day after day.
No wonder substance abuse is rampant. No wonder the steely persona is still held in high regard. Hide in a bottle or pretend it doesn’t matter. What other choices are there?
The ACGME is paying attention and has started an initiative on well-being. Medical education journals are publishing articles on wellness, resilience and burnout. Editor of Academic Medicine David Sklar even wrote a beautiful piece on everything medical education can and should be doing to help. But none of this work is yet addressing what’s really going down: the deep sense of loss being felt by the culture of physician-hood at every level.
Loss that too often manifests in the lost being lost to suicide.
Meaghan Ruddy, MA, PhD, BCC is the acting vice president for graduate medical education and director of transformative education at the Wright Center for Graduate Medical Education. She is an adjunct assistant professor of clinical science at AT Still University School of Osteopathic Medicine in Mesa, AZ, a volunteer faculty member with the Geisinger Commonwealth School of Medicine and a member of the STFM Faculty for Tomorrow Taskforce.
David P Sklar (2016). Fostering Student, Resident, and Faculty Wellness to Produce Healthy Doctors and a Healthy Population. Academic Medicine 91(9): 1185–1188.doi: 10.1097/ACM.0000000000001298