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Vulnerability & Mental Health In Medicine

Our healthcare system, and the culture of medicine that holds it up, is broken.

Among many other painfully real statistics, it's evidenced by the four hundred doctors—an entire medical school's worth of physicians—who die by suicide annually in America alone. This is the highest suicide rate of any profession. It's an epidemic so vast that it’s become a public health crisis as one million patients lose their doctors to suicide each year, made even more dire in the baseline national physician shortage. The state of healthcare in the U.S. is strained by priority-warped bureaucracy, oppressive documentation, the very real fear of litigation and financially-motivated impossible-to-achieve (and detrimental to patient care) quotas.

It’s an inconceivably complex issue without a one-size-fits-all solution, and the reality of that can feel so daunting that it paralyzes us from doing anything at all. But we don’t have to wait for larger bureaucratic change—as the great Arthur Ashe said, “start where you are, use what you have, do what you can."

As healthcare professionals, what we have is each other and our positions on the inside where we're uniquely able to influence dialogue, challenge destructive assumptions and practices by calling out problems in the moments they arise and use our voices to elevate what matters most rather than hiding behind the unfortunate excuse "this is just the way it's always been," which has been used to perpetuate a culture of systemic abuse of healthcare professionals and suboptimal care for patients.

No More Excuses.

For starters, the absurd societal practice of placing our healthcare professionals on pedestals, creating a power distance between provider and patient that denies the provider their humanity, disempowers the vulnerable, breeds isolation and cuts everyone off from the truly healing power of authentic human connection, is one of the ways we inflict the most harm on each other as a society. Somewhere along the way we’ve forgotten the very most important thing—that medicine is as close to love as it is to science—to quote Dr. Rachel Naomi Remen, and that at the end of the day we are human beings taking care of human beings, doing the best we can to facilitate healing—a process in which we become empowered to live our best lives possible despite the hands we've been dealt, whatever that might look like for us.

Enter: The 31 days of #VulnerabilityinMedicine campaign in spirit of Mental Health Awareness Month this May.

All month long we’re sharing snapshots of our humanity through the lens of vulnerability on social media in hopes of creating a dialogue strong enough to transform culture and we’re combating powerful things like isolation, disconnection, shame and burnout along the way.

Vulnerability, according to renowned researcher, public speaker and author Brené Brown, is an engagement in the growth, risk, failure, emotions and discomfort that are inherent parts of human life. It's a means of connection to who we really are, a willingness to lean into what matters most and to embrace the inherent discomfort, uncertainty and messy imperfections that are unavoidable parts of life. Vulnerability isn't about being weak, it's about being upfront about the fact that "weakness" is inherent to personhood and recognizing that there are far wiser ways to deal with our humanity than pretending it doesn't exist. Vulnerability, in short, is bravery. And, most importantly, it's the path to true purpose and meaning in our lives.

In a world where rampant provider burnout, disconnect and suicide is profoundly straining our healthcare system, we need to understand, promote and practice vulnerability—now, more than ever.

Over the course of the last few weeks, hundreds of individuals across all disciplines and levels of training have come together to human beings first and healthcare professionals second. Here are some of the raw, truthful, brutal and beautiful stories that have been shared through the campaign thus far:

“I work at an inpatient psychiatric hospital. Half of my patients attempted suicide or experience suicidal ideation and the other half are there for substance use treatment, or both. Most days I’m filled with immense joy working in this field. Watching someone in my group create and dig deep into their most painful memories and process and share they don’t want to give up on living. That they have hope that they will get better and want to keep fighting. Nothing comes close to these moments I get to witness.

I couldn’t imagine doing anything else for a career than be an Art Therapist. But with those days come the other days. When some past patients are continuously readmitted to the hospital. Either because they relapsed again or their suicidal ideations have returned. These brave individuals have relentless acute mental illnesses and they are desperately seeking safety within themselves. They keep coming back and that is just incredible, but I can hear it in their voices and see it in their bodies it is exhausting as well. Knowing a crisis brought them in and meeting them where they are at too is something I have had to learn to process for myself as their therapist. I can’t take it home with me. But of course it affects me.

My family, friends, strangers—literally from my Uber drivers to a date, when they ask what I do and when I say, “I’m an Art Therapist at a psych hospital,” often respond the same—that they could never do it and that I must be so strong. These are authentic kind and empathetic responses and I appreciate them, so much. However just because this is my job doesn’t mean I have thicker skin than anyone else. I hear narratives of trauma and violence and witness tears and break downs and patients who are so psychotic and out of touch with reality that they are reacting with aggression Monday through Friday. 8:30-6. It does affect me. I leave work and want to unpack it all. Sometimes it’s really easy and sometimes it’s hard. I get home and my head and body and heart are full and so I don’t talk to anyone until I’ve found a place and space to release these emotions.”Victoria, artist and art therapist

....

"Could I have saved them? No. Would they have died anyways? Probably. I don't know. I’m not God, but it certainly feels like I failed when I tell a family their loved one just died. Not all families take the news well. Sometimes they scream at you and say mean things and you can’t calm them down. There’s no coming back from death. No second chance. They feel what they feel, and you can’t always bring comfort. It sucks. It feels like shit.

I’m writing this so you know [when you fail that] you’re NORMAL. Just marinate in your failure. You’ll be ok. There doesn’t need to be an epic win afterwards. Maybe your story will be 'I failed my exams and didn’t get into residency so now I’m a consultant.' Shit happens. That works too. We don’t talk about death honestly and we don’t talk about failures honestly. I worry about the suicide risk among us physicians a lot. Sometimes you just fail. Life is still worth living." - Roozehra, feminist and critical care physician

....

"I’m one of the lucky ones. Anorexia Nervosa has the highest mortality rate of any mental disorder. It changes your brain function, turning you into an unrecognizable (and usually nasty) version of yourself. The daily battles have negative effects on friendships, relationships, jobs, school, and more. Recovery often takes years and years of medical treatment and therapy, sometimes out of town and most of which insurance won’t cover. You become a burden to your family and the guilt is immense.

It’s Mental Health Month and there is an incredible #vulnerabilityinmedicine campaign going on right now. I’m one of the lucky ones because I did recover, but not without my eating disorder leaving it’s mark. It changed my friendships. It altered my career (mostly for good now that I’m in med school, but at times previously I definitely didn’t perform my best.) I missed out on lots of fun during my teenaged and college years. I often wonder how many of my weird “oh it’s no big deal” symptoms are actually because I messed with my body for so long. And now, despite being passionate about removing the stigma and proud of how far I’ve come, I worry how it will affect my applications. Will residencies see this as a flaw, a weakness, a “red flag?” As if it wasn’t competitive enough, now I’m going to be judged for something I couldn’t help. Something I worked hard to overcome and, to be honest, I think shows strength and character and perseverance more than anything else. But I’m encouraged to hide that big part of my life because the stigma is most definitely not gone. I’m determined to stick to my values and prove that it can be done. Let’s keep talking about this stuff, and not just this month." - Clare, eating disorder advocate and third year medical student

....

“We work so hard to obtain some of our identity. Our titles, the ones we worked to acquire, often require a certain amount of persistence and resilience. I wanted to be ‘Manar the Physician’ before I knew I wanted to be anything else. I had to learn over the years that I first had to earn the title of ‘Manar the medical student’ and grow comfortable in the discomfort of that.

What I’ve found to be pretty funny is that after all the work to earn this temporary title, I have found myself in rebellion of the box that that title puts me in, as though being a medical student means you are that and only that. But here is what I also am: A storyteller who understands the world in prose and copes with it in verse, a diehard Palestinian who sometimes wakes up in the middle of a flashback about life back home, and open my eyes in disappointment when I find that I am not there. I can’t handle spicy food, I am a huge fan of Captain America, and I will never ever skydive. My favorite color is pink and anything sparkly, and my biggest pet peeve is people who forget that a conversation involves more people than themselves. I am terrible at compartmentalizing. I repeat, terrible at it. I tend to overthink until I’m stuck in the middle of a circle and don’t know how to get myself out of it. The news about back home affects me more than I wish it did because again, I am terrible at compartmentalizing. I am a bubbly person by nature, and it scares me how much of it I’ve lost in the last few months. I am not a hopeless romantic, but I love the hope that is in companionship. I worry that one day I won’t be able to leave work at work, and that it will get the best of me. My favorite place besides Palestine is behind a microphone where all the titles fall and I let my words lead my way, and I am usually just as curious as everyone else as to what Manar is going to speak this time, what story she has wrestled with, what thing has she coped with. There is more than just one box to check for my titles.” – Manar, first year medical student

....

"On one recent long shift, as I settled in to what I thought was sure to be a quiet and boring call, the emergency room dealt us a wild card. The next 16 hours were spent coding, then recoding again and again...and one more time finally stabilizing a rather sick patient. I called the patients spouse to alert her things had turned for the worse. The nurses, RTs, my incredible fellow, and co-resident worked tirelessly to keep the patient alive. I left the bedside to explain to the spouse what was going on. I will never forget the cry she let out when she collapsed to the floor in tears.

This morning, after we rounded on the still critically ill yet stable patient, his wife appeared in the threshold of the resident room doorway. 'I don’t know if you all believe in god, but what you did was a miracle and i cannot thank you all enough.' We hugged and I choked back tears of my own.

It's so easy to drone on through these long days and forget that what we do matters. We saved a life that night and it didn't dawn on me until this morning when I hugged that woman. These moments keep me going and help me push through 27-hour call and missed social obligations because there really is no better feeling. As much as I hate this training process, I love the magic of medicine." - Mike, medical illustrator and internal medicine resident

....

"I vividly remember my residency program director telling me that there's 2 types of psychiatrists: those who have lost a patient to suicide and those who haven't. Dealing with grief has been my biggest struggle in my career as a psychiatrist. I once told one of my patients that if she died by completed suicide, I would be sad...I would miss her...and that I'd wonder what more I could've done to prevent it. Telling our patients these personal feelings isn't something we learn in training, but it's something I've learned after losing several. It felt right at the time, and I know that it was therapeutic.

I'm surprised when patients tell me that they're shocked to learn that I'd be impacted if they were gone. As if I had a tough exterior and training that prevented me from feeling such things. But it hurts. I am human. The dreaded phone call from the medical examiner's office is something that I fear every day. Whenever my therapist brings up material that trigger such feelings of loss, I hold back my tears until I can no longer prevent the tears from flowing. And each time I hear about another one of our colleagues who die from suicide, I can't help but think of the emotional pain they must've endured.

We are brought up into this profession to be competitive with each other, to feel ridiculed if we don't know the answer, to tolerate working 30 hours straight, to view our peers as weak if they can't keep up with demands. As I type this, I'm trying to find excuses not to post because even though I'm an established psychiatrist, I'm still afraid of how I'll be perceived." - Vania, mental health advocate and psychiatrist

....

“Two years ago I was a third year medical student completing my surgical rotation. I was also eight months pregnant. I knew many surgeons who operated well into their third trimester, and I would be no exception. I was excited to learn. On my first day, the resident greeted me with indifference. A glance at my abdomen, a glance away. Instructed to take a seat. “He treats all students like this,” I thought. But his apathy toward me continued. He ignored me during case presentations, even when I knew answers others did not. Rather than being challenged like other students, he left me alone. There was limited teaching, limited interaction - a clear difference from other students.

Maybe his behavior was unconscious, or perhaps he thought he was doing me a favor... I’m not sure. But he treated me differently because I was a pregnant woman, because of his presumption of what that meant. It was as if he placed me into a “maternal category,” one that questioned my competence and commitment to medicine. I felt cheated out of learning, and worse, he made me feel invisible and valueless.

I worked hard anyway. I found allies among other students and staff physicians (many of whom had been pregnant themselves). I found other ways to learn, and still did well on the rotation. But I never confronted the resident. I downplayed it all and made excuses. There were power dynamics at play, grades at stake. I wish I would have spoken up. I would say this to him now: ‘Having a baby hasn’t lessened my commitment to medicine. It has not made me an ineffective doctor. Raising my daughter has increased my empathy toward humanity and my capacity to love. It has trained me to persist despite periods of fatigue and physical pain. Discriminating against those who bring life into this world degrades the medical profession and lessens the perceived value of human life. Yes, women may choose to have children during medical school, but don’t forget that they are future doctors. Train them. Challenge them. Inspire them. And change your mind about their worth.’ – Laura, mother and internal medicine resident

....

“As a mental health advocate, much of my time and energy is spent trying to improve the mental health of others. However, over the past 3 weeks, I’m grown a better understanding and appreciation of burnout. I was diagnosed with bipolar disorder 7 years ago and been able to drastically improve my management of my mental illness. Yet since starting medical school, I’ve put academics in front of my mental health. My first year of med school has been great. So far, I’ve passed all my classes, and even lost 30 lbs since matriculation. I simply assumed this would translate into proper management of my bipolar disorder. In reality, I’ve been ignoring insomnia creeping back into my life.

Since the start of school, I’ve struggled with quality sleep, especially surrounding exams. Fueled by stress and too much caffeine, my sleep has deteriorated over this past year. Over the past month, my insomnia reached an apex from a lower back injury. I couldn’t lay normally in bed from the pain. Even after minor surgery relieved this pain, I wasn’t able to exercise regularly until the wound healed. The past month of poor quality sleep brought back feelings I felt in the deepest moments of depression. It was unnerving. Did a lose my ability to manage my illness? Thankfully, I behaved differently than 9 years ago. Rather than turning to a bottle of whiskey to put me to sleep, I turned to my friend Richard and I told others what was going on. They all encouraged me to seek help. Yesterday, I had my first therapy appointment with Dr. Joy Staley, our school counselor. I’ve made calls to local psychiatrists to book an initial appointment. Gone are the days I’m ashamed to use the mental health system. Gone are the days I deal with my struggles alone.” - Logan, first year medical student

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Real systemic change is made up of millions of small moments when we could’ve stayed quiet but chose instead to speak up. It isn’t big or flashy or legal or dogmatic. It’s just you and me starting from where we are with what we have and vowing to do better. Doctors, nurses, physical therapists, occupational therapists, speech therapists, art therapists, respiratory therapists, pharmacists, psychologists, physician’s assistants, nurse practitioners, dentists, veterinarians, medical technicians, paramedics, patient advocates, current and pre-health students of every kind, I hope you’ll join us in shifting the focus of our medical culture from perfection to humanity. We are so much stronger together than we could ever be apart.

So, tell us—who are you, really?

Share your stories of what matters most using the hashtag #vulnerabilityinmedicine, tag our hosts @jess.g.johnson ・ @mike.natter ・ @shannydo ・ @speakoutmedicine ・ @freudandfashion ・ @thefemaledoc ・ and our sponsor @medelita_gram who will be graciously donating all kinds of beautiful prizes to celebrate participants, from tailored embroidered white coats, to unbelievably comfortable anti-bacterial and stain-resistant scrubs, state of the art stethoscopes and gift cards that allow you to dream big.