Authors: Amy Ondeyka, MD, Inspira Health Network and Loice Swisher, MD, Drexel University College of Medicine. Submitted on Behalf of the Mental Health Task Force of the Resilience Committee.
Another year is upon us. We have a new crop of fresh faced interns hanging on our every word and trying to learn the culture of the new place they will call home for the next 3-4 years. The current residents are advancing on the totem pole and have more responsibilities. Life stressors are ever present and job stressors continue to climb.
As educators, it is easy to get lost in the clouds, thinking of resident medical education as a series of check boxes to complete. Then, a reminder appears that jolts you back into reality. One such reminder was the recent letter sent to residency programs from Dr. Thomas Nasca, CEO of the ACGME. His letter highlighted the importance of improving wellness in our programs. He discussed an article published in Academic Medicine, that reviewed almost 400,000 residents who entered an ACGME accredited residency program from 2000-2014. Of those, 324 individuals died during residency. The second most prevalent cause of death overall was suicide (trailing just behind neoplastic disease), which was also the leading cause of death in male residents. The majority of suicides occurred in the first two years of training, and the most at risk time of year was the first quarter (July-September) and third quarter (January-March).
Applying this information, programs should establish an in-depth wellness orientation process at the beginning of the first year, as well as provide reminders during the first and third quarters. This in-depth orientation process for new residents is also called Onboarding. Onboarding is the time in which programs should set expectations, discuss transparency, detail the signs of depression and burnout, and explain the resources that they provide.
If your residency does not already have a wellness program in place, then now is the time to start one. The first item on the “to-do” list of your program should be a resident onboarding lecture. Main topics to highlight for an informative lecture are listed below. You can further expand on these topics throughout the year in a wellness lecture series.
Onboarding Lecture Toolkit
Transition Points and Challenges
Some individuals will enter residency with a pre-existing mental health history, which you will likely not be aware of. These residents may be at the greatest risk, and it would be wise to set some expectations up front. Plainly state that if anyone has a pre-existing medical or mental health condition, then it is expected that they continue to take care of themselves and set up continued medical/mental health appointments throughout their residency. A perceived lack of time to fit in appointments is a significant barrier that needs to be addressed and overcome. Residents should be able to work with program leadership if they have difficulty finding this time.
In general, the switch from medical student to resident is a high risk transition point. Many individuals will be moving from a different state, leaving their support system behind. Residents will have to deal with real patient responsibilities, poor patient outcomes, long work weeks, lack of free social time, heightened study requirements, and other program related tasks. They will have to develop coping mechanisms, hopefully healthy ones, to deal with the above.
A full discussion of these challenges and transition point dangers up front may be helpful. Let the residents know that program leadership is always available to talk and help.
Let the residents know if you have a formal process in place to help at-risk individuals. Discuss what concerns they may have if they choose to seek help. Do they fear repercussions within the program itself or with the state licensing board? Do your best to get these fears out in the open and then make a plan for how to overcome them.
Emphasize Well Being
Residents should be encouraged to continue with activities that have brought them joy in the past. Highlight the importance of exercise, which can include joining a gym, signing up for a community sports team, or partaking in the latest fitness trend. Improving one’s diet is a continuous goal. They can buy healthy snacks and meals to bring on shift, which can help to avoid the unhealthy cafeteria options, or join a mail order meal plan. Getting enough quality sleep is another topic of discussion. Efforts can include investing in blackout curtains, a white noise machine or phone app, a fan, or just using ear plugs.
Develop a mentor program if you don’t already have one. Consider assigning “families”, which include one resident from each year of training and a faculty member. These “families” can be introduced via email prior to the start of the year and should continue with meetings throughout the year. This will help to provide residents with a built in support system.
Learn the Signs
Discuss potential warning signs of depression. These can include increased irritability or anger, decreased work performance, isolation or withdrawal, mood changes, increasing alcohol use or other risky behaviors, and strained personal or professional relationships.
During your orientation lecture, show the suicide prevention video created by the Mayo Clinic and the National Foundation for Suicide Prevention.
Share the Resources
Most hospitals provide an Employee Assistance Program (EAP) to employees free of charge. There is typically a website with many resources to peruse and a phone number to call. The phone number will connect the employee to a trained counselor who will assess their needs, including suicide risk factors.
They will assist the employee in making a predetermined number of free counseling appointments. This entire process is confidential and the hospital and/or residency program is not notified in any way. These programs not only focus on depression, but they can help with a wide range of mental health issues, family issues, substance abuse, and even topics like financial counselling.
Provide residents with the national hotline numbers, such as the National Suicide Prevention Lifeline (1-800-273-TALK), and the National Hopeline Network (1-800-SUICIDE).
Let the residents know that they can always talk to program leadership, who can help to decipher if the issues are typical challenges of residency or something more serious. They can provide support by making adaptations such as schedule changes, an enhanced study timetable, additional learning opportunities such as a procedural skills conference, or even just personal advice. Establishing a faculty member as the Wellness Chair, whom the residents can seek out, may alleviate any reservations about “going to the program director.”
These are just some of the topics that can be included in your resident Onboarding lecture. Residency is a challenging and difficult time period for everyone. Depression, burnout, and suicide are becoming increasingly present in our field. The first step is to acknowledge these issues by coming out of the shadows and starting an open supportive discussion within your residency program.