The special stress of residency

“If we have a system where asking for help is not a normal part of medical training, it creates this perception that if you’re struggling and need help, it’s a weakness.” – Dr. Stephanie Klein

Statistics reveal that burnout, depression and suicidal ideation are at a peak during residency, compared to any other time in a physician's career.  Why is residency such a difficult time and how can we ensure people get the support they need? 

In this episode, Dr. Caroline Gérin-Lajoie speaks with Dr. Stephanie Klein about losing her twin brother to suicide, just as he was beginning his residency, and the wellness program she created specifically for residents, in response.

Want to learn more about physician wellness? Visit the CMA Physician Wellness Hub for curated, clinically-based tools, resources, and research on all the topics covered in this podcast.

This episode is available in English only.

Transcript

Episode Two

The special stress of residency

Caroline Gérin‐Lajoie (intro):

Welcome to "Sound Mind," a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin‐Lajoie.

For many physicians, residency is one of the most challenging times in their career. The demands are extremely high, and the learning curve can be steep.

In a 2018 national survey on physician health conducted by my colleagues here at the Canadian Medical Association, residents were 48 percent more likely to experience burnout than physicians, and 95 percent more likely to experience depression. They are also at much higher risk of suicide ideation. This is no surprise to Dr. Stephanie Klein.

In 2016 while she was still a resident, she founded one of Canada's first resident wellness programs at North York General Hospital, and, as she explains, it's a program that was prompted by a personal experience in her own life.

Stephanie Klein:

My story begins with my twin brother and I both accepted to medical school. He was accepted at Queen's, and I was accepted at the University of Toronto. Personally, I found parts of my medical training to be quite challenging. We were exposed to so many new experiences. There was a lot to learn.

I think most medical students today are very competitive and are used to succeeding, and all of a sudden, you have to change so much and learn so much in a short period of time. I had some of my own anxiety that I was experiencing, especially during the clerkship years. I was glad that I reached out at a time because I didn't know what I was about to face.

I'd say the most defining moment of my life came on July 3rd, 2015, that was when I received the news that my twin brother, who had just finished his medical training at Queen's, and was supposed to start his family medicine residency, that he had tragically taken his own life. It's really just shocking when you experience something like that.

The best way I can describe it is that it's like you're under water and you're trying to come up and gasp for air and I just came to the realization that the person who I was a few seconds ago is different from the person who I am now, and that life will never go back to how it was before.

We didn't have any warning signs. My brother looked like he had everything on the outside, but unfortunately, there was a struggle on the inside. There's a lot of medical professionals, medical students, physicians who are struggling in the same way. Suicide also brings with a lot of complexity. There's so many questions that will always be unanswered.

The way I've tried to cope with it is just knowing that every illness has varying degrees of severity, and suicide is a fatal consequence of depression, but it's not, in any way, a choice. The people who suffer from this, it's not within their control. Depression is an illness that causes millions of deaths each year, and it disproportionally affects our profession in medicine.

That's what led me on this journey to find out what we can do to address this problem. Over the last five years, I've been trying to bring some meaning to my brother's life and personal healing by raising awareness and starting programs that address mental health and suicide among Canadian medical students and physicians.

Caroline Gérin‐Lajoie:

Today, the Resident Wellness Program Dr. Klein started is still running at North York General Hospital and has been replicated in a variety of forms across the country. She's now the faculty wellness lead for the Family Medicine Department at North York and a clinical teacher at the University of Toronto's Department of Family and Community Medicine.

I began our conversation by asking her to connect her own very difficult experience to her journey as a wellness leader.

Stephanie Klein:

It was part of my healing process. I think everyone handles grief differently. My way of coping with it was learning and discovering everything that I could find out about why this happens. I had no idea that suicide was something that affected doctors to the extent that it does.

Then, I realized it's actually a phenomenon in our profession, which I couldn't understand, because we have the greatest knowledge and access to healthcare, yet we're the ones who utilize it the least.

To cope with all the emotions and the difficulty I was having at the time, I threw myself into researching and understanding. That's what led me to find out what strategies and programs we can implement to address the issue.

I was just starting my residency a few months after the loss of my brother. During that time, I was starting at Family Medicine Residency at North York General. Wellness was not yet a concept. This was back in 2016. It was in its early stages, so we didn't have a wellness lead or a wellness curriculum. That was my goal.

I presented this outline to my program director for a program called Gaining Resilience In Training, and we called it GRIT for short. We based it off of...Actually, Vanderbilt University had their own wellness curriculum at the time and they had key elements of wellness, like you have intellectual wellness, emotional wellness, physical wellness.

Our design was to develop initiatives within each of these areas so that we could promote work‐life balance for residents in the program and allow them to access supports. It also would destigmatize accessing those supports if it was part of the curriculum.

Initially, we had wellness retreats, various social events, yoga sessions, mentorship, and other activities, but what branched from that was the development and implementation of Balint groups into the residency curriculum. Balint groups are a type of peer support group, and it's named after a British psychoanalyst named Michael Balint. They're basically small groups of individuals who meet with a facilitator.

The purpose of the meeting is to explore your own emotional experiences through providing patient care and some of the challenges that we encounter in a supportive environment with your peers. There's so much stress and difficulties that we face on a daily basis, but we don't always have the time to debrief about these.

The Balint groups allowed for sharing vulnerabilities and for deeper connections to form. We had protected time and space for this during the academic half‐day for the residents. There were a few groups of about six to eight residents that would meet several times over the year.

Our sessions had specific themes like managing patient expectations or uncertainty in family medicine, and how medicine can impact your personal life. Overall, the program was very well‐received and it still runs today, so I'm pretty proud of that.

Caroline Gérin‐Lajoie:

Can I ask you specifically about the importance of making the program a mandatory part of the curriculum? Because we know curriculums are incredibly busy, and it's difficult to find space with so many areas to cover, why was it so important to you that the wellness programming be a mandatory part of the curriculum?

Stephanie Klein:

You're right. There's always people who want to add things to the curriculum, and there's always more to learn in such a short period of time, especially in the family medicine residency. Making the Balint groups mandatory was critical to its success, because first, it meant that they didn't have to use their personal time to benefit from this initiative.

It was during the academic half‐day, not on their evening or weekend. We were able to get that time, because we showed that it enhances some of the other skills that are important for developing physicians like communication, and self‐awareness, and professionalism. We were given that time easily.

It also meant that all of the residents had to participate, and it wasn't just a self‐selecting group. That can also destigmatize that sharing of vulnerability that I talked about. We know that being vulnerable is not something we're used to in medicine or talking about our weaknesses or mistakes that we've made.

A lot of people are uncomfortable with that, but this entire program was designed around encouraging open discussion and sharing. I think residents overall felt very supported in that environment. Lastly, it showed the residents that their program cares about them and cares about their wellness by dedicating time to it.

They formed closer connections with their peers. When I created the Balint group, I was also in the Balint group and I still have a group chat going with my co‐members to this day. Other programs reach out to me to incorporate it into their residencies, so it's definitely gained a lot of traction.

Caroline Gérin‐Lajoie:

Can you tell me a little bit more about the importance of incorporating the Balint groups into your programming?

As you said, this creates that safe space for people to talk openly, to make themselves vulnerable but in a place of support. Almost like it was the secret sauce, or that the active ingredient in your programming. Can you tell me more about why it was so important to create that space for the trainees?

Stephanie Klein:

Yeah. It was important, because we're so used to performing at a high level at all times. Also, we're used to being evaluated at all times, whether it's exams, or what they're called ITERs for the residents. You always feel like you need to be on. This time and space for the Balint group, there was no evaluation. There was no didactic part to it.

There were certainly some people who were not initially comfortable with this idea of open disclosure. Even if there were some residents who stayed quiet, we did a research project on this after. We found out from them that even just listening and connecting to their own experiences, that they gained benefit that way.

It was therapeutic for them to recognize that, "Oh, I'm not the only one who is experiencing this difficulty. My colleague just shared a story that I know I've experienced before." That, again, destigmatizes talking about our challenges. It's not something that you have to sign up for.

I guess, what I'm trying to say is that it's hard to pick up the phone and speak to your doctor or go to a therapist. A peer group is like a non‐confrontational way to support one another and still get the therapeutic benefit.

Caroline Gérin‐Lajoie:

I was curious to hear a little bit about your thoughts on the mental health of residents during training. You've mentioned before how it is an incredibly challenging and difficult time for most residents. Can you tell me a little bit more about your thoughts and what we know about that?

Stephanie Klein:

The research has shown that medical trainees, they start out with mental health outcomes that are similar to their age‐matched peers. Then, there's something that happens during their training. It's the demands that are placed on them that causes skyrocketing rates of anxiety, and depression, and burnout.

For residents, their rates of depression are doubled than what it is for the general population. Most residents would say they know a colleague who's died by suicide. The problem only gets worse as you progress in your training. In terms of why this happens, I'd say the number one factor is the fact that stigma is a barrier for not asking for help.

The CMA launched a survey a couple of years ago, where they identified that only 15 percent of respondents would actually ask for help for their mental health condition. For trainees in particular, they don't have a lot of control over their schedules, and there's a lot of expectation that comes from the program, but also the unrealistic expectations that we place on ourselves.

That leaves very little time to have a wellness routine or to see a therapist. You always want to be present, even if you're suffering. The stigma drives this fear that if you do ask for help or take time off, that you might have a red flag on your profile, or it might affect your standing in your program or the ability to get the job that you want with increasing competition.

The problem with this is if we have a system where asking for help is not a normal part of the medical training, it creates this perception that if you are struggling with a mental health concern and need that help, that it would be viewed as a weakness. Then, that would lead to further denial or minimization that there's even a problem in the first place.

A lot of shame students might experience and further withdrawal, but at the same time, all the demands and pressure to succeed and build a career is still there. We know that the 24‐hour call shifts can cause a significant amount of fatigue and that sleep deprivation worsens mental health.

We have all of these factors going on, and then something like a mistake can happen, or maybe a patient dies, or you get critical feedback from a supervisor, or maybe a personal life stressor occurs.

We have a cohort of individuals who are used to being the best at everything. Then, all of a sudden, these challenges come up, with the unsustainable lifestyle that eventually, something has to give.

It's a slippery slope, I would say, between getting by, to feeling emotionally drained and overworked, to feeling anxious and depressed, turning to substance use, and having suicidal thoughts. That's what has come up in the research.

Over the last few years, we've made some progress, but much of this was going on in a culture of silence. If we're having conversations like the one that we're having today, and I know there are a lot of physicians out there who are trying to role model behavior that promotes wellbeing and work‐life balance, then hopefully we can start to change the culture. It does take time.

Caroline Gérin‐Lajoie:

You've elicited multiple factors that may have a huge impact on the health and wellbeing of trainees, and I would say also practicing physicians. I wonder if you had comments on whether these factors are more individual factors. Are they our medical culture factors, or are they factors that stem from our training environments?

I say that because one of the factors that you talk about is the perfectionism that is part of our personalities, and part of what draws us maybe to medicine and having very high expectations of ourselves. On the other hand, that ultra demanding and competitive environment may be linked to factors from the environment or the culture.

I'm just wondering where you see these factors fit in in those dimensions, and at the end of the day, whose responsibility is it to start changing things and decreasing stigma?

Stephanie Klein:

You're right in that. There's multiple factors that contribute to this. There's the workplace factors. Medicine has changed drastically over the last few decades. We have more complex patients. The systems don't support that complexity, and it seems like we have to do more with less.

We know that for every one hour of patient care, there's two hours of paperwork that goes along with it. That's a huge driving factor for burnout as we didn't go to medical school to do all that paperwork. We want to also be there for our patients. That's maybe more of our individual factors, that we all went into this profession to help people and sometimes, or I should say all the time, we make sacrifices.

I think medicine glorifies the concept of self‐sacrifice and even at times, neglect, which makes having work‐life balance even more challenging. The system has pressures for productivity over our own wellbeing, and then our own expectations and the perfectionism fall in suit.

In terms of how we change this, changing the system does take time. I know there's a lot of governing bodies that are working on strategies for this, but in the meantime, if we can do something from an individual point of view like having a Balint group, or having wellness routines or wellness messaging, or ways that you can reach out.

I know the physician health program has put out a lot of messaging to support doctors that we can at least build our own individual resilience while the system takes time to change, but a key piece of this is that it's not all on the individual, and blaming ourselves contributes to the problem here. It's a much bigger issue.

Caroline Gérin‐Lajoie:

Thank you for responding. I think you've said it quite well, that historically the individual physicians were made to feel accountable for difficulties in their wellness or challenges in their wellness. However, we're now at a point where we can recognize that this is very much a shared responsibility.

That involves everyone, the individuals and the system and our medical culture and the practice or learning environments that we live in day to day, so I would agree with your comment. This is multifactorial, which means that the solutions are also multifactorial.

Stephanie, I would like to hear a little bit about the success that your program GRIT has had. What kind of feedback have you been hearing over the years since the program has started?

Stephanie Klein:

Since I implemented it a few years back, now we have, every year, new residents coming in and becoming the wellness lead and running the wellness curriculum.

Again, I'm very proud to have had that lasting impact. Same thing with the Balint groups, that we still have them running to this day. I even was given the opportunity to present the project overseas in Scotland in the hopes that they've implemented something over there.

I've been really pleased to see the positive feedback. I think people just want this safe place and to feel connected. We know that social connection reduces burnout and makes us feel better, especially during these times, in the pandemic and being away from our usual routines.

As we've already talked about, we know that there's going to be inherent difficulties in the work that we do. At least having this program, it gives you an opportunity to commiserate over it and feel supported. The feedback has been positive.

Caroline Gérin‐Lajoie:

Through the discussion today, Stephanie, you've talked about the importance of stigma as a huge barrier in seeking help and being proactive with our health and wellness. Can you talk about how impactful stigma is, and what your thoughts are on what we can do to decrease it?

Stephanie Klein:

I strongly believe that stigma kills. It prevents people from seeking help.

There is no physical condition that we would not seek help for. If you break your arm, people come to sign your cast. If you're diagnosed with cancer, they say that you're fighting a battle with cancer, but if you have a mental health problem, no one is waving the flag for feeling depressed. It's a big secret. Some people might even view it as a character flaw, which is the sad part of all of this, because it's not. It's a medical condition like any other medical condition.

Within our profession, for example, if there's questions on the licensing body certifications asking you if you've ever been diagnosed with a mental health condition, or substance use, and how this could potentially affect your competency for practice, that's something that we know can reinforce that stigma.

We have a system that, as I've described, is designed for burnout and contributes to the mental health decline of our doctors. I know that the leaders are aware of this and are actively trying to address stigma within our governing bodies.

A lot of work is being done by Canadian Medical Association and the OMA in changing the messages and providing resources for doctors. The wellness hub with the CMA has a large amount of information. Hopefully we'll see that the stigma breaks down over time.

Caroline Gérin‐Lajoie:

If I may add to that, people like you having the courage to share their personal story and lived experience one person at a time, this will help us to speak more openly, and to prevent issues with mental health. Every person can play a part in reducing stigma. I also wonder, looking back, if the success of this program has even more meaning, because of the way that your story started​?

Stephanie Klein:

Yeah, it does. I'm someone who needs to keep my mind occupied, and so recovering from the loss of my brother, I needed something to bring joy back into my life and feeling like I can make a difference and an impact.

Nothing is going to bring back the loved ones who we've lost, but at least in creating these programs, I've already seen a huge change, and I'm being asked to be part of various committees and starting other programs. That's stemmed from all of this. It's been a journey that has helped me personally and professionally.

Caroline Gérin‐Lajoie:

Your engagement continues in other ways. Recently, you've become a member of a new physician suicide prevention task force in Ontario. Would you like to tell us a little bit more about that?

Stephanie Klein:

Yeah. I do feel like I've come full circle from when I started this journey. I didn't know what suicide was all about until it happened to our family, and that this is something that happens disproportionately to doctors.

I remember coming across an article at the time that said, "Suicide is an occupational hazard for physicians." Now, when I come across that, my question is, why should we accept this?

Now that we've struck up this task force, the Suicide Prevention Task Force that's supported by our college, with the goal of raising awareness that this is a problem and addressing the factors that contribute to it, it does provide this validation to me, to my family, and I'm sure to many other family members and colleagues who have been affected by suicide loss within our profession.

If we start to keep track and share these stories and learn more, I do believe that change can happen.

Caroline Gérin‐Lajoie:

Dr. Stephanie Klein, I want to thank you for sharing your story with us and for everything you've done for trainees in your province, and, as we now have heard, potentially across the world with the innovative programming that you've developed at your Centre. You are truly an inspiration, and you're certainly creating a new generation of leaders in the area of physician wellness.

Thank you for joining us today in this wellness podcast. It's been great speaking to you about such a crucial topic. Take good care.

Stephanie Klein:

Thank you for having me​.

Caroline Gérin‐Lajoie:

You've been listening to "Sound Mind," a podcast about physician wellness and medical culture. It's produced by the Canadian Medical Association in collaboration with PodCraft Productions.

If you are looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca.

I'm Dr. Caroline Gérin‐Lajoie. See you next time.

Transcription by CastingWords