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Words fail

August 9, 2009

This past week, I got a late night e-mail regarding a meeting – of unknown reason – at the hospital the next morning. We residents arrived in the room, sure that each of us was going to be in trouble for, say, dressing unprofessionally, or that there had been a medical error on our part, or perhaps our program had not been accredited. As we looked at each other quizzically, one face that had just stepped into the room told it all: it was much, much, much worse.

A new friend and colleague had taken her own life. She was an enthusiastic, warm, and ambitious woman, someone who I knew would be a good friend by the end of the year. We do not fully appreciate the circumstances of her death, and the shock of learning of this event seems not to be lifting.

We are sad. She was a beautiful and bright light, and it is difficult to even fathom this loss. If I prayed, I would beg that she found peace, and that those who love her well will find their peace too. It is impossible to understand what she went through; those who know her intimately may beat themselves up for not detecting some subtle foreboding hint – but there may have been none. No warning. She was happy and healthy 2 days prior.

On that terrible day, there was an incident at her work. This involved a medical error that had serious implications but the consequence to the patient fortunately was not dire. In striving to explain the inexplicable, our consensus has been that the stress of making this mistake, and the self-imposed expectations of excellence at all times were factors in why she may have felt overwhelmed. No one stopped her as she walked out the door. Even if her demeanour did not reveal it, she was deeply distressed. Could someone stopping her to debrief have made the situation better? We don’t know. But it should have been done anyway.

It feels inappropriate to share these details, but I cannot but do so. I do not want to offend her memory. I must learn, YOU must learn. We ought not to continue on just as we always have. Something failed her. Sometimes people don’t reach out for help when they need it. Sometimes it is our job to reach out to them. I’ve made the mistake of not taking the time to “debrief” someone before, and I regret it.

Even though I had only just begun to know my colleague, I am shaken. She wasn’t so different from me; we were even the same age. I have colleagues with the same ambitions as she. What stress, what stress we are under. It is eternal, and so we think it normal. We justify it as ‘part of the job’ and downplay the extent to which we are swimming in it. We have great power, and great responsibility like Spiderman does, only it’s much much greater and much much scarier. And we could drown in it. New physicians ARE well supported, but that doesn’t mean the job itself becomes easier or less personally demanding. All the ‘physician wellness’ resources in the world don’t mean anything when you are too burdened to access them.

This makes me feel vulnerable. Not in the way a tragic accident suddenly takes a young life (and we all fear for our mortality), but in the way that a choice I’ve made (a career in Medicine) puts me at risk of crumbling. And I will make major mistakes. I will probably indirectly kill a patient through an unintended effect of medication, or through neglect of some important aspect of their care. I will be devastated, and I’m afraid of it. I am lucky that my family and friends are always willing to listen when I am upset. There is an open door and I find it easy to call even in tears. I hope that if I face something enormous, I have the strength to reach out for help, but if she – and she was strong – didn’t, I’m scared that I won’t either.

What an incredible person she was. I wish I had the chance to know her well, as her laugh and smile were infective, and her passion a big reason to look up to her.

We miss you dearly, and had a pint at the QW for you. I can see that you are so loved and will always be.
for P: Nous partageons votre peine en ce moment de deuil. Nos sincères condoleances, à vous et à votre famille.

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19 Comments leave one →
  1. August 9, 2009 5:48 pm

    You are right to speak up, Jess. We love you very much.

  2. Doclectic permalink
    August 9, 2009 6:04 pm

    See the American Foundation for Suicide Prevention Website for their project on prevention of medical student and physician suicide.
    It is a problem all of us in medicine face. Times are getting better, there are more programs out there for help, the stigma of depression and reaching out for help are lessening, but there remains work to be done.

    http://www.afsp.org/index.cfm?page_id=05804002-E8F4-13AB-2D4B97A0815A2744

  3. August 9, 2009 6:22 pm

    I can only imagine the pressures, and the long shifts, and the scary control over life and death that you can hold as a doctor… but if ever you find yourself in that spot where you don’t want to reach out for help… remember, nobody is going to judge you or find you wanting if you ask. If you can’t find anyone to talk in your seemingly excellent support system, Jess, call 911.

    I don’t know how many people I’ve known who’ve died at their own hand, but it’s too many.

  4. Mark permalink
    August 9, 2009 9:09 pm

    Although there are tonnes of programs for physicians one of the most important pieces in our emotional well being is a good social network.

    Residency is hard for that. Many people move at the start of their residency, an immensely challenging time, and when working resident hours it is hard to build the social networks.

    Not to mention the instability in our work environment. Every month we are on a new rotation, with new colleagues (attending physicians, residents and nurses) and new politics to feed into. We must prove our basic competence again and again.

    With “distributed education” it is even more challenging, we work in more and more remote locations without a peer group and we move between cities. This makes developing a local support structure nearly impossible.

    I count myself lucky that when I have made mistakes I have had good friends to fall back on (and who could carry my drunken body home). But I have also felt the sting of failing a colleague. This is a horribly difficult and real issue. Thank you for speaking to it.

  5. Free confidential resources available to all permalink
    August 9, 2009 11:54 pm

    Hello everyone,

    My love and thoughts are with you all at this difficult time.

    The entry above emphasizes the need to debrief incidents as they occur. Perhaps some feel too upset or proud to discuss their fears, feelings or errors with colleagues or even family.

    Fortunately there are free, confidential, professional counselling services available to all Health Authority employees.

    I checked the websites, and below are the phone numbers for the Employee and Family Assistance Programs in your Health Authority:

    VIHA WIDE (North, Central and South)
    Services provided by INTERLOCK
    1-800-663-9099

    VCHA and PHSA
    Employee & Family Assistance Program (EFAP)
    750 West Broadway, #514
    Vancouver, BC V5Z 1H4

    Toll-free: 1-800-505-4929
    Phone: 604-872-4929
    Facsimile: 604-872-7430
    Email: help@efap.ca

    These services are FREE, CONFIDENTIAL. I believe these services are available 24 HOURS PER DAY immediately on the phone or by appointment during business hours. They have a wide range of business hours, so you will always be able to find a time that can work for you. Please keep these numbers in your wallet to ensure that in a crisis you always have a number to call. And always remember that if you are feeling desperate, dial 911.

    I would strongly urge each one of you to call tomorrow to make an appointment for yourself for a full debriefing of this and any other things that might be happening for you.

    Being in the Medical Profession and dealing with life and death on a daily basis, going to see the counselors at your Employee and Family Assistance Program for a debrief weekly, monthly and/or as needed throughout the year has come highly recommended.

    Love to all,

  6. August 10, 2009 7:02 am

    I came via Grunt Doc. Very well said and very sad. This is what all doctors dread – to make an error that harms someone. I have never done something large (that I am aware of) that caused harm. To some extent I consider that luck (as most docs would admit).

    The hard part now is to try to turn the bad into good. Learning from the tragedy does redeem it in a small way. Even putting up that post is a small bit of good against this huge tragedy.

  7. August 10, 2009 10:37 am

    The tragic occurrence you describe has been repeated far too many times before. Your first few lines say it all: “we were…sure that each of us was going to be in trouble for…a medical error on our part…”

    You are brave and wise beyond your years to observe that “I will make major mistakes”. I hope that you believe it. Everyone in medicine for any period of time has made a mistake. And because some of our decisions are so consequential, and technology imperfect and the human body so unpredictable, some of your mistakes will cause injury, perhaps even serious injury or death. This is a fact of life in medicine that is overtly denied in medical school and residency, because everyone is slightly afraid that to admit that it can happen will make it more likely.

    Thank goodness we do have wellness programs in training these days, and counseling services. Assuming you are in BC, you have an excellent and supportive Physician Health Program in the province with many confidential resources. But all of these resources can be superfluous if you are taught, overtly or covertly (“we were sure we were going to be in trouble”) that making mistakes is not acceptable in medicine, not even in medical training. You are human. That’s part of what makes you caring and conscientious young physicians. Training is the time to make mistakes, when there are others about whose job it is to notice and correct them.

    And as human beings you have a need to reach out and share and learn from situations such as this. You are doing that in this blog. But there must be an actual belief on your part and that of each of your young colleagues that reaching out is MOST crucial and potentially life saving when we have not achieved that impossible goal of absolute perfection in everything that we do in medicine.

    So when you know that another has had an upsetting experience, you have a moral obligation to one another to go beyond the “See no Evil, Hear no Evil, Speak no Evil” norm of the profession and offer a listening ear, an arm around the shoulder, or a prophylactic “pint at the QW” and steer your colleagues to available counseling if they seem to be obsessing over an error or experiencing symptoms of depression. The first lives we must care for and save are our own.

    I have many materials available on my website, http://www.black-bile.com. Most of the critically important information about Physician Depression and Suicide can be found in an article at http://emedicine.medscape.com/article/806779-overview.

    And incidentally, Jess, words didn’t fail. You have used them quite effectively to open the conversation on this lethal issue with your followers.

    • August 10, 2009 2:35 pm

      Thanks for the lovely note and the useful links; there will certainly be a legacy to her memory which may take the form of more training in dealing with errors, emotions, and so on. We will plan it at a later date, as currently all of our attention is focused on celebrating her life and a memorial that will reflect her energetic and compassionate spirit.

  8. August 10, 2009 6:04 pm

    Also came here by way of GruntDoc – hearing about this is not only incredibly sad, but as you allude to, terribly puzzling as well. One of the EMS services I work for had an employee take his own life back in April. Nobody knows why, to this day, although the prevailing suspicion is that it was due to a relationship that went bad. And he was really young: took his life the day before his 25th birthday.

    Prayers for your colleague. And for you all that are left to deal with the aftermath as well.

  9. August 11, 2009 2:52 pm

    Very sad indeed.

    Found your site via Grand Rounds.

    The Cockroach Catcher

  10. August 11, 2009 7:09 pm

    I am deeply saddened by this tragic loss. Medical training can have the lowest lows of a physician’s life. Although I never considered self-harm I have been in this young doctor’s place before and been the resident that felt things would never get better.

    This was a beautiful and thoughtful memorial to your colleague. I hope your blog of your training will be a testament that despite the dark days you will rise above.

    -Dr D

  11. August 11, 2009 7:24 pm

    Amazing post.
    That feeling of vulnerability makes you a better doctor. You think of patients as people and not as bed numbers or rooms. Don’t ever lose it.
    Louise is right about the wellness resources. Make the time to go. Remember the story about the rocks. http://www.epmonthly.com/whitecoat/2009/06/the-rock/

    • August 13, 2009 5:22 pm

      The rocks. I hear that one all the time, and it is important to heed. I sometimes feel like my rocks are in a blender instead of a jar. However, I am close as can be with my family and I pride myself in doing a lot of things outside of medicine, even if it means I don’t have the time to read as many journals or memorize as many facts as I should!

      Getting settled in a new place means I have probably put a lot of small rocks in before big rocks… but one can also shake the jar out and rearrange things a bit. I hope.

  12. August 12, 2009 11:38 pm

    very sad, a tragic ending to a life recently devoted to helping others. whether from inevitable mistakes or unfair blame, physician suicide is a definite problem:

    http://emedicine.medscape.com/article/806779-overview

    you go into this profession to help others, and when you make mistake, or someone threatens to sue you for your good intentions, it is extremely damaging. the longer you’ve been in practice the more likely you carry some low level PTSD.

    • August 13, 2009 5:16 pm

      We are lucky in Canada that things are not as litigious as in the states; I can’t imagine having that extra pressure on top of everything else.

      She was an incredible woman, as could be seen by the fact that we had to fetch more and more and more chairs for the memorial, and then it was standing room only. It’s still surreal though.

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