A Personal Story of Loss by Suicide (Part 3 of 5) by Mukta Panda, MD
I took a deep breath then and shifted into gratitude. I looked up to the heavens and said to myself, “It’s no coincidence—I don’t believe in coincidences, only confirmations.” On that very day, it so happened that I was flying to Chicago for a symposium on physician well-being hosted by the Accreditation Council for Graduate Medical Education (ACGME). I would ponder this tragedy there.
Hazards of the Healing Profession
The impetus for the ACGME symposium had come from the family of a medical resident named Greg Feldman. If you search online for his name, you will see that his promising accolades included being a star student at Harvard Medical School, volunteering for surgical mission trips to help children in Rwanda, roles in leadership, a prestigious residency at Harvard followed by an award-winning surgical fellowship at Stanford School of Medicine. He had been four months into another fellowship in Chicago. But in 2010, at the age of thirty-three, Greg became one of the disproportionate number of physicians who end their own lives. His family charged the ACGME to do something about this crisis of physician suicide and burnout.[i]
A letter from his family posted online reads, “Greg had one of the brightest personal futures and groundbreaking careers ahead of him. We believe, however, that the professional experience he endured in the months before he died triggered a rapid, overpowering unraveling.”[ii]
The symposium was limited to 100 attendees. We met in small groups to discuss possible solutions to practical but complex questions. What could be done to promote resilience? What would facilitate early identification and recognition of distressed residents? What efforts would reduce the stigma that surrounded seeking help? How might we ensure access to care? How could we intervene to help grieving communities heal? (The thought of helping a grief-stricken community heal was very close to home.)
The second day, in small groups again, one question became a seed that would begin to grow in my heart. “What would you be able (willing) to commit to do personally/organizationally over the next year?” Was there a way I could go back and effect an organizational culture change?
The symposium was a time for catharsis. Two close friends were there who gave me a safe space to be open and share my frustration, anger, and sadness without feeling like I needed to make a point. It was a gift to have someone to listen to me. I asked for their suggestions about how to approach change in my institution. “How would you even begin to have such conversations with people?”
One possible first step, they suggested, would to be gather a group of residents and colleagues who had the opportunity to work with the good physician and simply allow them to speak.
Being at the symposium was a blessing because it gave me a sense that I could do something positive. I could use this tragic event as an imperative to move things forward. Being there, hearing other stories and the tools other organizations had used, gave me renewed energy, a burning desire, to move institutional change forward. I was invigorated to go back to work and start a well-being committee. People knew I was upset about what had happened to our good physician. Honestly, I didn’t care if they thought I was also a victim. I decided I was going to utilize that empathy, because it meant they would listen to me.
The day I returned to work after the symposium, I had a voice message from his wife, who I did not yet know personally. I mustered the courage to call her back, unsure what she might say.
“Dr. Panda, I don’t know what to do. He has so much stuff in his office. He always spoke so kindly of you and you helped him. Can you use some of his stuff?”
I had three students going into dermatology, so we walked upstairs and looked through his office together. Throughout his career, he had never failed to go to annual conferences on dermatology at the Mayo Clinic. He had a book from the 1963 Mayo Clinic proceedings. One of my students was going to study dermatology at the Mayo Clinic, so he took that book. I kept a picture of him at a health fair. Then we found lecture notes in a manila envelope. He was so organized. He had created a lecture on skin lesions for the residents, complete with facilitator notes and a PowerPoint. A thought came to me. I immediately called his wife and told her what we had found.
“I’d like to re-give this lecture,” I said. “My students will give it in his honor to celebrate him. Would you be willing to let us do that?”
She said yes. My medical students and I planned the event, inviting his family, residents, and colleagues. We delivered his lecture. We celebrated his life with our own stories in his honor.
In some ways that celebration began healing my wound. I had felt I needed to do something. More so, I wanted to celebrate and affirm him as the astute, kind and compassionate physician and educator he was. I wanted him remembered as somebody who had given so much of himself as a human being, as a friend, as a physician, as a teacher, as a community servant. And as a father, a grandfather, and a husband.
The Trouble with the Triple Aim
We walk through a journey in the health care system that outright devalues non-financial, qualitative, non-normative results in favor of quantitative measures. It’s easier to show stakeholders a progression of numbers on spreadsheets. And often by hacking the quality of patient care, there is the added bonus of slashing expenses. The shift to the Triple Aim, introduced in 2007—with three well-intended initial goals of improving the patient care experience, improving population health, and reducing per-capita health care costs—garnered widespread appeal.
Sometimes referred to as the Triple Aim, and other times as The Holy Grail, these ambitions may have had unintended consequences, as well-intended experiments often do. The Triple Aim left out one of the major stakeholders—the physicians. What about them? What about understanding what connected physicians’ passion to their purpose? While the original three goals were admirable, the population-wide focus on the Triple Aim prevented too many of us from noticing the increasing rates of physician burnout, depression, and suicide.
That over half our physicians nationwide are affected by burnout is a rampant rate of eye-opening proportions. Such an alarming reality in the US is beyond acceptability. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs.
In 2016 the Triple Aim was amended with the Quadruple Aim of improving the experience of providing care by bringing back joy and meaning to medicine.But is it too late? Much damage has already occurred. What is the cost of a human life?
My good friend couldn’t keep up with the quantity dictate. It destroyed him, along with thousands more physicians that we know of who are suffering immeasurably.
Unlike many other industries with serviceable quantitative measures, health care cannot be forced into like categories. Does a quantity of a single human life make any sort of sense? An outcome of one human loss is called a tragedy. Outcomes of many human losses are called statistics. Statistics generate celebration for those who process them or are benefited by them, but we no longer have the luxury of placing peoples’ lives on par with a chart full of numbers.
The great stories in health care are about patient/physician relationships. How can a quantitative statistic be measured and celebrated over human connection? We must retrain our focus to celebrate the “who” along with the “what” in reports of improved patient care and population health.
Medical students and residents are asked to write personal statements for their medical school and residency applications, describing why they are answering the vocational call to health care. In their reflection essays, that very element of human contact shows up over and over as the most important theme. These essays speak of our noble intentions to join a vocation of serving, quenching our thirst for making a difference—we speak of connection to our purpose, we speak of personhood. We speak not of power, possessions, or position.
But how do we as educators support and encourage our students’ eloquent answers? Do we give our students and residents the proper tools, or make them aware of even a modicum of necessary self-care habits and resources? Seldom.
Conversely, we celebrate those who are able to separate mind, body, and soul. We further equip young men and women with highly developed obsessive-compulsive tendencies. We demand superhuman hours that effectively produce a mass workaholic mentality.
We as educators must take responsibility for this debilitating situation. We are crying for help to teach this invisible or hidden curriculum. If we and those we work with do not recognize the need for returning humanity to our classrooms, then we are in grave danger of becoming nothing more than robots. Evidence shows how physicians lose our sense of purpose very quickly, as early as after the first year of medical school training. Our systems need to be scrutinized. We need to look deeply into ourselves. Are we the role models we want to be?
I wonder if the pendulum shifted too far over to the non-human pole. I often feel that we in health care put on so many protective layers until they hardened into a self-protective yet destructive shell and we’re forgetting who we are. Further, we aren’t allowed to be human beings because the model we are held to feels dehumanizing. Every human being needs a sacred space where each belongs and can be brave enough to show up authentically. But currently we do not have permission to come to work wholly as ourselves.
What is the solution? We cannot survive if we continue to follow inhumane institutional practices. The calcified layers we’ve assumed must begin to crack so that we can see the light at the end of the long figurative tunnel. We need the national dialogue already initiated between various stakeholders like the Accreditation Council of Graduate Medical Education, the National Academy of Medicine, the American College of Physicians, the Arnold P. Gold Foundation, the Collaborative for Healing and Renewal in Medicine (CHARM), other leaders, and those with “boots on the ground.” We must rediscover our shared covenant and values.
Along with this national discussion, we each need to take it upon ourselves to walk our talk. Remaining true to your values takes courage and practice. Only then will there be a paradigm shift in the prevailing culture of health care.
[To be continued…]