PTSD and surgical residents: Everybody hurts… sometimes

Accepted Manuscript PTSD and surgical residents: Everybody hurts … sometimes Theresa Jackson, Amanda Provencio, Karalyn Bentley-Kumar, Chris Pearcy, Taylor Cook, Kevin McLean, Jake Morgan, Yoseful Haque, Vaidehi Agrawal, Brittany Bankhead-Kendall, Kevin Taubman, Michael S. Truitt PII: S0002-9610(17)31418-6 DOI: 10.1016/j.amjsurg.2017.10.014 Reference: AJS 12566 To appear in: The American Journal of Surgery Please cite this article as: Jackson T, Provencio A, Bentley-Kumar K, Pearcy C, Cook T, McLean K, Morgan J, Haque Y, Agrawal V, Bankhead-Kendall B, Taubman K, Truitt MS, PTSD and surgical residents: Everybody hurts … sometimes, The American Journal of Surgery (2017), doi: 10.1016/ j.amjsurg.2017.10.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT PTSD and surgical residents: Everybody hurts…sometimes DISCUSSANT I compliment RI PT DR. CHRISTIAN DEVIRGILIO (Torrance, CA): Dr. Jackson and her colleagues for truly a great presentation. The 57% rate of PTSD or at least one PTSD‑related symptom in The relationship between M AN US C your study is alarming but not surprising. PTSD and burnout is novel and important. In the past five years, the percent of physicians with burnout has increased, and surgeons are particularly at risk. Burnout often proceeds depression, and an estimated 400 physicians That's the equivalent of one entire D commit suicide each year. In addition, burned‑out TE medical student body class every year. surgeons are more likely to commit self‑reported medical error, so AC C attention. EP I'm glad that your group is bringing this vital issue to our I have several questions. It is noteworthy that complaints of bullying seem to dwindle as residents advance in training. residents are less likely to be bullied? Does this mean that senior Or do senior residents develop more resilience towards bullying? Given that the feeling of bullying decreased as residents advanced in training, yet PTSD did not decrease, it seems though the ACCEPTED MANUSCRIPT shift in the source of PTSD to something else later in training. Please comment on this. How do you foster resident camaraderie which is one of the things in your paper that you mentioned was very important? burnout in residency. RI PT I would like to use an analogy of youth sports and PSTD and When I played soccer as a child, the season ran from September to mid-December, and by the next summer, I was M AN US C gnashing at the teeth with desire to play again. Nowadays, my son, for instance, when he plays club soccer, he plays 50 weeks out of the year, practice three or four times a week and travels literally every weekend to games. year in high school he was burned out. By his senior Should we then have sent such of the problem? Or is the answer really to address the root TE resilience towards this? D a child to a wellness program or a program to develop better Please comment on that. EP We are in an era where residents get fewer and fewer opportunities for autonomy, yet in your paper you suggested that AC C inadequate supervision worsens PTSD. How do we strike a balance between autonomy and this problem? Finally, in the police force, if there's an officer‑involved shooting, the officer is taken off duty, and a team of psychologists work with the officer to mitigate the potential for PTSD. In medicine, we witness a patient death after a trauma and then we go on to the next patient. What are your thoughts on creating a similar ACCEPTED MANUSCRIPT program for medicine? Thank you very much for a great presentation. RI PT CLOSING DISCUSSANT DR. THERESA JACKSON: Pertaining to whether or not bullying, why the decreased frequency of PTSD among higher levels of What I wasn't able to present was that when we looked at M AN US C residents. the prevalence of PTSD at each PTY level, it ranged from 13 to 23%, and there was no statistically significant difference. this as it's the nature of the disease. PTSD. I interpret As a PGY1, they develop If you do not address the root of the problem, if you don't D address the PTSD, this could be a life‑long problem. TE In terms of how to foster camaraderie, I think at the root of camaraderie is friendship, teamwork, and respect for one another, EP and particularly respecting each other's differences and weaknesses. I think that residency program directors can lead by AC C example by almost creating mandatory activities for residents to foster this friendship and teamwork, and by again leading by example and not endorsing the culture of bullying and criticism. In terms of possible wellness programs, I agree, it's wonderful that hospitals are looking at physician wellness. think that that's important. I do But what they are missing is this may not be a physician problem, but this may be an institutional problem ACCEPTED MANUSCRIPT and maybe we need to look at the risk factors for the development of burnout and PTSD and address those first rather than doing tertiary prevention and trying to mitigate already‑established burnout. What I did not address in my talk was that in my paper I risk factors for PTSD. RI PT also looked at 12 additional work environment variables that may be Of those included autonomy, camaraderie, hospital culture, and, interestingly to me, autonomy was not a risk Rather, camaraderie, poor M AN US C factor for the development of PTSD. hospital culture, reduced support and supervision were all risk factors. I think what this is showing is that some programs are doing it right, and some programs aren't. The fact that 30% of surgical residents are violating work D hours may make me think that those programs are also not following TE through with the other ACGME mandatory requirements which include improving support and supervision for the safety of our patients. EP I hope that my paper is suggesting that each program needs to be looked at individually, what we are doing well and what we can AC C improve upon. Finally, in terms of whether or not we need to incorporate debriefing sessions, I think that’s not a bad idea. In the Air Force, or in the military, in the airline industry, in the police force, after a death, we had debriefing sessions. talk about it at all in residency or as attending. However, we don't I think that potential ways to improve on this would be to incorporate a special ACCEPTED MANUSCRIPT M&M once a month where we talk about how we felt or how an experience really impacted us. Additionally, I think that potentially enforcing psychological sessions for residents in terms of talk therapy every This would allow residents to feel RI PT semester is not a bad idea. comfortable with an outlet if they do end up developing substance M AN US C abuse problems or are at risk of suicide. DISCUSSANT DR. MARIA ALLO (Los Altos, CA): interesting topic. This is a really D At Stanford, we had a resident jump off a building during TE his first year of Fellowship, having survived a Stanford residency, and that prompted the university to start a program very much like EP what you describe, which does deal with a lot of these issues. I also had a colleague who committed suicide, and even six AC C years later it's still a very wrenching, emotional experience. But my question for you is, is this unique to medicine and surgery? Or is it symptomatic of a larger societal problem? It would be interesting to see if screening people, for example, in their first year after joining a corporate law firm, and the few years between that and becoming a partner, created the same kinds of numbers. ACCEPTED MANUSCRIPT Also, whether some of the other specialties, like dermatology or ophthalmology, had the same kind of numbers among your I ask for your comments on that. CLOSING DISCUSSANT DR. THERESA JACKSON: RI PT trainees. I think you are absolutely right. M AN US C It's hard to know whether we are special in medicine or if this is just another high‑intensity profession. All I know right now is that the general population has a prevalence of PSTD of 9.7%. far range from that. 22% is a We do plan on looking at additional specialties as well as Fellows and attending surgeons to see if this rate of PTSD Until we have further data, I don't know that I can D is consistent. TE really comment on whether or not a dermatologist is experiencing as AC C EP much stress at work as I feel like I do on a daily basis.