Chaim B. Colen, MD (left)
Young Physicians Representative Section of the CSNS
Grosse Pointe Woods, MI
Roy S. Hwang, MD (center)
West Virginia University Department of Neurosurgery
Morgantown, West Virginia
Cara Sedney, MD (right)
Assistant Professor at West Virginia University Department of Neurosurgery
Morgantown, West Virginia
Two suicides by residents in New York City have caught the attention of the media and likely caused concern for many neurosurgeons involved in resident training. Drs. Pranay Sinha and Alexander Sowa McPartland both wrote poignant pieces detailing the losses that left faculty and colleagues shocked and wondering if they should have anticipated and intervened. Are these two recent deaths a coincidence or an indication of a dangerous, under recognized epidemic? Has the onslaught of mandates increased the stress on residents — either directly or through sapping resources from faculty who are essential in supporting resident trainees; thus preventing these catastrophic events?
Physician psychosocial stress is a well-known issue and the resulting suicide rates in physicians is twice that of non-physicians. Residents and those early in training are at increased risk for burnout, psychiatric morbidity1 and suicide.3 Physician psychosocial stress correlates with “high demand,” “low control,” situations prevalent during residency.2 This stress is particularly concerning because the current generation of residents, (“Millennials” born 1980-1999) are more collaborative and team-oriented with fewer internal reserves to deal with psychosocial or organizational stresses than “Generation Xers” (born 1964-1980), who are more independent, self-sufficient, and flexible.4 Millennials may require specific interventions to learn optimal coping mechanisms. In addition, residency training programs may need transformation into more collaborative environments to provide better support. Recognizing stress and distress is the first step.
Top Risks for Physician Distress:
- Trainee status;
- Concomitant Depression; and
- Lack of constructive coping techniques.
Unfortunately, having the skills to intervene and take corrective action are not part of faculty training. Drawing on experience from other work environments, behavioral modeling and encouraging open, frank discussion, backed up by institutional resources specially designed to deal with the problem are all critical steps to take. Another important concept to appreciate is “resiliency.” Resilience is practically defined as an ability to deal with stress in a constructive way and “bounce back,” rather than becoming drained and burned out. While there is no way to directly measure a resident’s reliance quotient, indirect assessment is reflected in clinical performance, attention to detail, and interaction with nurses, colleagues, and patients.
- Low Level of control;
- Conflict between commitments at work and at home;
- Discord with coworkers;
- Debt load;
- Fear of litigation; and
- Poor patient outcomes.
An increasing body of research has dealt with ways to increase resilience in physician populations. Successful techniques identified transcended specialty and include:
- Engaging in recreational activity and secondary fields of interest;
- Maintaining contact with colleagues and family relationships;
- Self-reflection and self-demarcation;
- Proactive engagement with challenges;
- Continuing education;
- Appreciation for positive aspects of life; and
- Ritualized time-out periods.6
Recognizing that residency training encourages few of these techniques, many programs now incorporate social gatherings and similar on a regular basis. A key concept, however, is internal — the importance of self-awareness and recognition of maladaptive responses to stress as an initial step towards building more constructive stress responses.7 Studies on sleep deprivation and history of depression did not correlate with burnout but lack of confidence, anxiety, and disorganization were predictors.5 Skills in resilience are increasingly being taught to residents and medical students through such programs as Mayo Clinic’s “SMART” program (Stress Management and Resiliency Training).
Like many challenging issues within medicine and society, the ultimate key is honesty, openness and a willingness to change. Neurosurgeons remain committed to training the best residents so future generations will have great specialist who can care for them. Incorporating a greater awareness of the impact of psychosocial stressors, the risk of suicide, and the value of building resiliency are essential components of that training.
Table 1: Resources for residents and physicians
|Mayo Clinic Physician Well-Being Program||http://mayocl.in/1EjGPmH|
|Well MD – Stanford University School of Medicine||http://stanford.io/1gt19fO|
|Mindfulness in Medicine – University of Wisconsin||http://bit.ly/1KZBzcQ|
|Sotile Center for Resilience||http://bit.ly/1IEySdI|
|Mindful Practice – University of Rochester||http://bit.ly/1J6bgEj|
- Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2004 Jul;86-A(7):1579-86.
- Von dem Knesebeck O, Klein J, Grosse Frie K, Blum K Siegrist J. Psychosocial stress among hodpital doctors in surgical fields: results of a nationwide survey in Germany. Dtsch Artzebl Int. 2010 Apr;107(14):248-53.
- Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among US medical students, residents, and early career physicians relative to the general US population. Acad Med. 2014 Mar;89(3):443-51.
- Mohr NM, Moreno-Walton L, Mills AM, Brunett PH, Promes SB. Generational influences in academic emergency medicine: teaching and learning, mentoring, and technology (part 1). Acad Emerg Med. Feb 2011; 18(2):190-199.
- Ripp J, Babyatsky M, Fallar R, Bazari H, Bellini L, Kapadia C, Katz JT, Pecker M, Korenstein D. The incidence and predictors of job burnout in first-year internal medicine residents: a five-institution study. Acad Med. 2011 Oct;86(10):1304-10.
- Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med. 2013 Mar;88(3):382-9.
- Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013 Mar;88(3):301-3.