"Stress & Depression" [CD1.2] | The LIFE Curriculum

"Stress & Depression" [CD1.2] | The LIFE Curriculum



well I think I figured out how the ED works the way i see it is a hierarchy of screams the attendings scream at the rn's RN scream at the lpns and then everybody screams at us oh speaking of screaming here comes mother Simmons and she saw cranked up to well I don't mean to abandon you guys but I gotta go where's Alicia I don't know she's presenting she better get here fast good morning good morning everyone wanting a person appears we're one person short dr. Simmons good morning everybody sorry I'm afraid of running a bit late how nice of you to grace us with your presence shall we begin please our first patient is seven year old Ana Ortiz as you will recall she was admitted yesterday on a emergency basis with the chief complained of abdominal pain and after being diagnosed with acute appendicitis underwent a successful Evans activi the same day her recovery has been unremarkable and what about the lab tests the blood work um a CBC let's see white blood count 15-point 5072 seggs seven bands of the urinalysis on admission it was 10 to 15 WBC 025 RBC no bacteria those are the admission tests what about this morning's I i think if you'd examine the lab tests you realize that you're giving us all results what about today's you need to be much better prepared for rounds so we don't waste time okay anyone anyone what are the most recent results did you update this patients shots are you here is anyone home I just can't do this today I can't do this most of us who have been involved in physician training programs have encountered residents who stumble in their careers the manifestation can take many different forms a resident known and admired for even tempered behavior suddenly begins to react with anger even hostility to minor inconveniences someone noted for meticulous attention to detail inexplicably has difficulty managing their paperwork why the sudden change in behavior what's causing it behavioral symptoms often provide important clues to underlying problems in this case the behavioral clue is the poor performance Alicia our resident is performing well below the expectations of the faculty member let's take a look at how the attending might handle the situation just portrayed a little more productively how she might treat Alicia's behavior as a symptom requiring closer scrutiny good morning everyone sorry I'm afraid I'm running a bit late how nice of you to grace us with your presence shall we begin please our first patient 27 year old Ana Ortiz as you will recall she was admitted yesterday on emergency basis with the chief complained of abdominal pain and after being diagnosed with acute appendicitis underwent a successful appendectomy the same day her recovery has been unremarkable and what about the lab tests the blood work CBC let's see white blood count fifteen point fifty seventy two eggs seven bands of the urinalysis on admission it was ten to fifteen WBC 025 RBC no bacteria but those are the admission tests what about this morning's I look why don't we go see the patients first let's get them taken care of Alicia I need to see you later in my office we need to sort things out okay okay stress during residency is inevitable it isn't necessarily bad in fact it can be a great teacher and a terrific motivator however when stress leads to mark distress it can lead to poor performance and even illness or impairment it is impossible to determine from this brief and yet what exactly is going on with this resident without more information but it is obvious that she is not performing up to expectations after working through this section of the Life program you should be able to describe common stressors and predict adverse outcomes resulting from chronic stress recognize symptoms indicative of depression anticipate suus risk and outline strategies for responding to the depressed resident physicians face enormous learning challenges during the years of the residences stress associated with learning experiences can serve as a great motivator encourage and facilitate the acquisition of knowledge and clinical skills when stress exceeds the adaptive capacity of the individual however it becomes destructive the ramifications for the professional and personal life of the physician can be serious responses to stressors are both unpredictable and highly individual what one resident will experience as stimulating and exciting emergency surgery for example can overwhelm and intimidate another a few weeks ago they brought in a guy that been in a car crash a real disaster horrific what a mess there wasn't a square inch of his body that wasn't damaged electrodes everywhere tubes coming out needles going in suddenly hit me this guy who probably had a life of some kind maybe a wife children this guy could die die and I would be one of the ones that it would depend on Jen my friend dr. Gordon she loves stuff like that me I just about lost it residents if they are to become successful practitioners must be able to cope with any number of stressors generally stressors fall into three categories situational personal and professional situational stressors are connected with the training program and include such things as time demands and heavy workloads personal stressors are related to the resident and family relationships these include the effect of the demands of the profession on important relationships limited budgets and lack of leisure time professional stressors are associated with the process of becoming a physician and include patient responsibilities and mastery of the clinical literature the effects of stress on the body and mind have been well documented stress that exceeds the individual's adaptive resources can lead to physical emotional changes and in an attempt to cope with the effects of stress the adaptation of maladaptive behaviors unfortunately these behaviors neither reduce the misery associated with stress nor resolve the stressful situation in fact they eventually may result in position impairment due to alcohol or abuse of other legal or illegal substances any one of which is sufficient to hinder patient care there are of course more positive ways of dealing with stress the first step is for residency programs to acknowledge and appreciate the effects of stress the second step is to try to prevent it the third is to recognize the signs and symptoms of miss manage stress and finally the fourth have policies and plans to deal with it when intervention is required every program in fact would be wise to adapt and teach stress management strategies early on in the residency as a way to help physicians through the rigors of the training period beyond stress management programs must also address mental health problems in residents particularly depression all supervisory personnel need to be alert to its potential presence oh hi Alicia come on have a seat thank you how are you doing good yeah well let's get right to it Alicia I'm really worried about you you are a skilled and compassionate physician with a wonderful wonderful career ahead of you you've done some really solid work since you started in my service but then the last two weeks have noticed a change have you well look I don't want to upset you but I have called your program director what Alicia we're here to help you not to threaten or intimidate you let's get this straightened out let us help you we can you know in the last two weeks you've been struggling is it a problem of understanding what you need to do no I I just I don't think I'm doing too well my husband isn't very happy here and I I just feel overwhelmed I'm so tired no energy sometimes I think last night when I went home my husband took the twins out for ice cream I just SAT and cried I just like to just quit just be done with it I just can't keep this up Alicia how many times have you shown me just how well you can keep up that you're a skilled resident I would hate to see you throw in the towel now after you've worked so hard to get to where you are now look I know that residency is no picnic everyone in training goes through these p even if they don't show it and you you have a marriage twins who need a lot of attention but in past conversations I do know that your husband has been your major support but if he's not doing well here I guess it's very stressful for you both I have to be frank with you when interns are stressed my one thought one worry is and this is very very important and that is whether they have considered hurting themselves so I ask you this question have you had any thoughts of suicide no no not really that sometimes it seems would be a lot easier if I were dead sometimes in the midst of so much stress it is easy to lose perspective and you know it would be inappropriate of me to try to assess exactly what you're going through and that's why it's critical that you see someone who is a little bit more removed from the program who can be a little more objective is that okay with you I guess I'm willing to try anything in the scenario just presented dr. Simmons the attending modeled several behaviors for us she noticed the residents poor performance and addressed it with a resident in a private setting she arranged a meeting away from the immediate pressures of the inpatient service she elicited and listened to the residents perspective she provided support and empathy she normalized the situation by describing Alicia's reaction as not all that unusual and she offered hope also extremely important she assessed for suicidal ideation notice that dr. Simmons did not try to diagnose or treat the resident but did reinforce the need for an objective professional to provide help program faculty & program director should resist the urge to diagnose and manage resident stress even if they are capable of managing similar symptoms in their own patients this blurs the boundary of the teaching relationship their obligation is not to treat the resident but to help the resident gain access to the appropriate resources finally and very crucial is that she connected the resident with the program director and close the loop by asking the resident to confirm that the meeting has occurred sometimes the resident will benefit from counseling a change of rotation or even a leave of absence this is especially the case if the resident suffering is severe as in depression depression is as common in physicians as it is in the rest of society it is also a major risk factor for suicide physicians commit suicide at higher rates than the general population women physicians are at particular risk medical culture does not invest a great deal in physician mental health therefore residents should be encouraged to establish their own source of healthcare for both their physical and psychological well-being they should also be educated about depression and its consequences and help to understand the kind of protection they can expect in terms of confidentiality should they decide to seek help for themselves or their colleagues the module on burnout and career crisis has other suggestions you may find helpful identifying or diagnosing depression is not always simple and as a consequence it often goes unrecognized certain factors can mask the clinical presentation depression can also hide behind physical symptoms and finally it can cause social and sexual problems sleep disturbance and substance abuse a very important caveat is that except in an emergency no physician should treat a colleague or family member for depression or for anything else judgement can never remain neutral when the person being treated is close to the physician residents are colleagues and the mentoring relationship can make them seem almost like family members boundaries then risk becoming blurred because of the multiple roles faculty members must play with the residents faculty who treat residents cannot be effective evaluators and evaluators if they are to remain effective as such cannot treat residents this is true even when the disorder in question falls well within the normal scope of the senior physicians practice outside resources should always be used to identify and treat any medical or psychological condition affecting any resident after your resident has had an outside evaluation use the information provided to develop an education modification plan although the program won't be treating the resident it is essential that it ensures that they get time off to keep doctor appointments get frequent feedback on job performance and take care of themselves it is also very important to maintain confidentiality finally if the resident is not returning to a service where they can be directly monitored by program faculty aware of their situation permission must be granted on any other rotation the resident joins so that close supervision of the resident can be maintained fortunately the prognosis for depression is excellent with appropriate care most physicians recover completely and go on to resume normal and productive lives

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