Guilt and Guts; Sri Lanka & Seattle

elephant

Randomly, we choose to take a look at Sri Lanka, knowing so little about this interesting and beautiful country. Our curiosity revealed an exciting connection between Sri Lanka and our home, Seattle, WA, USA!

Sri Lanka:

Wikipedia: Sri Lanka, officially the Democratic Socialist Republic of Sri Lanka, is an island country in South Asia near south-east India. Sri Lanka’s documented history spans 3,000 years, with evidence of pre-historic human settlements dating back to at least 125,000 years. Its geographic location and deep harbours made it of great strategic importance from the time of the ancient Silk Road through to World War II. Sri Lanka was known from the beginning of British colonial rule until 1972 as Ceylon. Sri Lanka’s recent history has been marred by a thirty-year civil war which decisively ended when the Sri Lankan military defeated the Liberation Tigers of Tamil Eelam in 2009. A diverse and multicultural country, Sri Lanka is home to many religions, ethnic groups, and languages. Sri Lanka is a republic and a unitary state governed by a semi-presidential system. Sri Lanka has a universal health care system that extends free healthcare to all citizens, which has been a national priority. 

Sri Lanka Preterm Births – Per WHO/Born Too Soon:

Preterm births in Sri Lanka are 10.7%, and the Sri Lanka is ranked 81 globally in the number of preterm births. “Born too Soon” also reports that Sri Lanka is one of seven low- and middle-income countries that have halved their preterm deaths within a decade (as of 2012). The additional countries include Turkey, Belarus, Croatia, Ecuador, El Salvador, Oman and China.

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Our journey to Sri Lanka led us to: INTERGROWTH-21st –

intergrowth21

The International Fetal and Newborn Growth Consortium for the 21st Century, or INTERGROWTH-21st, is a global, multidisciplinary network of more than 300 researchers and clinicians from 27 institutions in 18 countries worldwide and coordinated from the University of Oxford. The INTERGROWTH-21st project was a multi-centre, multi-ethnic, population-based project, conducted between 2009 and 2014, in eight demarcated urban areas: Pelotas, Brazil; Shunyi County, Beijing, China; Central Nagpur, India; Turin, Italy; Parklands Suburb, Nairobi, Kenya; Muscat, Oman; Oxford, UK, and Seattle, USA. Its primary aim was to study growth, health, nutrition and neurodevelopment from <14weeks of gestation to 2 years of age, using the same conceptual framework as the WHO Multicentre Growth Reference Study, so as to produce international prescriptive standards for pregnancy dating, maternal weight gain, fetal growth, newborn size, the postnatal growth of preterm infants and cognitive development at 2 years of age. INTERGROWTH -21st developed scientifically robust clinical tools to be used to monitor and evaluate maternal and fetal wellbeing, as well as infant health and nutrition at an individual and population level (birth weight, head circumference, length standards). Through this project INTERGROWTH-21st developed Preterm Size at Birth References and Z Scores (Standard Deviations) and online browser based tools that enable birth weight, length and head circumference to be classified according to these international references. On Feb. 19, 2016 Intergrowth-21st announced the availability of Very Preterm Size of Birth References and Z Scores.

An article dated Dec. 11, 2015 in the Global Health Network (https://tghn.org/) reported:Sri Lanka becomes the first country to adopt the INTERGROWTH-21st Preterm Standards”

Webinar: In January 2014, Professors Stephen Kennedy and Jose Villar, Co-Directors of the Oxford Maternal and Perinatal Health Institute, and “chief architects” of the INTERGROWTH-21st Project discussed the objectives, design and emerging findings from the world’s largest collaborative venture in the field of perinatal health research.

Webinar Link: https://intergrowth21.tghn.org/about/intergrowth-21st-webinar/

 

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      Part 2 (Journeys of Grief, Guilt, Guts and Gratitude):- GUILT

  • Miriam Webster:  Simple Definition of guilt:
  • :responsibility for a crime or for doing something bad or wrong
  • :a bad feeling caused by knowing or thinking that you have done something bad or wrong

In the preterm birth community, guilt is often experienced in relationship to “What Ifs” and “If Onlys”, and many Partners within our community experience guilt in some capacity related to the traumas that connect us.

Healthy Children.org published this updated article (11/21/2015) “Common Parent Reactions to the NICU”. The article briefly addresses the range of reactions and emotions parents may experience following their first moments in the NICU, such as Fear, Anger, Loss, Guilt, Powerlessness, and Feeling on Display. Regarding Guilt the article states:

“It took us a long time to resolve our guilt. We asked the ‘what if’ and ‘why us’ questions for months. But we did nothing wrong. We had good prenatal care. What happened to us was nobody’s fault.

Most parents express feelings of guilt after the birth of a sick or premature baby. You may ask yourself, “What did I do to cause this?” or “What could I have done to prevent this?” And nearly every parent unnecessarily laments, “If only I hadn’t….” Mothers, especially, examine their lives since the day they became pregnant—wondering if they could have changed the outcome by making different decisions or if their circumstances had been different.

For most babies in the NICU, the reasons they were born sick or premature are not known. If necessary, let go of guilty feelings, which will give you more energy to care for yourself and your new baby. It is also important to try and share these feelings with the NICU team. Often the NICU team can provide answers and comfort”.

We sometimes lock ourselves into a “closet” of guilt,  perhaps to avoid taking action.  In reality, however, the door is OPEN!  Allow guilt to fade with the setting sun. Welcome in the light of transformation as the sun arises.

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Kathy: My experience of guilt was stronger more in relationship to the twin (Cruz) whom I feel (from a spiritual perspective) choose not to remain  in this realm, than it was in relationship to the surviving twin (Kat) due to the fact that I have had an opportunity to contribute in a positive way to Kat’s current  life journey. As parents we can identify a myriad of issues that we imagine we “may” be guilty of.  Guilt itself offers an opportunity to look more intently into an event, our motivations and actions, etc., but beyond expanding our immediate perspective guilt is not a feeling that contributes to the well-being of ourselves or others.  I encourage our community partners to choose love, take action, and positively transform our feelings of guilt in order to support our health and well-being, and in doing so the health and well-being of others.

Kat: I feel some guilt that my brother Cruz passed while I was able to survive our birth. I experience some guilt that my family was caught in the trauma of caring for a child that lived while living in the anguish of another’s passing. Some guilt still remains present in my heart when I am in the NICU or hear a story of a fellow preemie that passes or has a challenging outcome. Within myself I question “why did I make the estimated 15% chance of life for babies born at 24 weeks gestation?” Acknowledging my feelings of guilt allows me to take action, and to recognize and seize the opportunity to move the stagnant energy of guilt into a positive energy of healing, love and action. Healing and wholeness are a process…

buddah

Meditation is a powerful way to transform the energies of feelings! Abundant, diverse and free guided imagery resources are available on YouTube. We loveh The Honest Guys and recommend this Guided Meditation as a tool for transforming guilt into a positive energy.

GUIDED MEDITATION – Overcome Guilt ; The Honest Guys – Published on Aug 9, 2016

Some people find it difficult to overcome guilt, to forgive themselves. This can become a difficult load to bear. This meditation will help you to forgive yourself and leave the guilt behind you.

GUTS                                           lion

1.     Google: (informal) personal courage and determination; toughness of character.

guts

We travel, each of us, on a Hero’s Journey through life. As a Neonatal Womb traveler, we have all been challenged to choose love over fear, staying over fleeing, seeing over denial. Perhaps courage is the act of knowing ourselves deeply, accepting and creating space to experience the wholeness of who we are, and living within the integrity of our beingness with presence and compassion towards ourselves and others. We are a community of Heroes.

joseph

WARRIORS:

Are you familiar with Bethany Hamilton, the surfer who lost her left arm in a shark attack (2003)? Bethany resumed surfing about one month after the accident, and went on to win a national pro surfing title in 2005. Now, at 26 years of age, Bethany, a wife and mother, is an inspiration to many. This influential surfer is quoted as saying ““Courage doesn’t mean you don’t get afraid. Courage means you don’t let fear stop you” and “I don’t want easy, just possible”. Please enjoy this short video about courage, personal experiences, and choices of a young girl.

Bethany Hamilton: Shark Attack–The Real Story

 

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RESOURCES:

Journeys of Grief,Guilt,Guts & Gratitude

hawaii

“When your fear touches someone’s pain, it becomes pity, when your love touches someone’s pain, it becomes compassion.” -Stephen Levine

Our intent for the next few blogs is to openly address critical emotions that deeply, uniquely yet universally connect and impact partners within the Neonatal Womb community. So often within our community we feel we need to take this journey in silence, often alone with our feelings, even within our family and work family units. Currently, there is an abundance of grief related resources available to preterm birth families within the USA including diverse in-person, telephonic, on-line resource opportunities. We are aware of a clear and concerning lack of resources available to support our healthcare brothers and sisters through their experiences of grief and related emotions. Warriors, understanding grief will empower our capacity to fully experience and acknowledge our own emotional being as we journey forward, while empowering our capacities for empathy, kindness, joy, health and strength.

Part 1 – Grief

Dictionary.com: Definition of grief: noun

  1. keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret.
  2. a cause or occasion of keen distress or sorrow.

Kathy: The anguish and grief experienced by the mother represented in the video below is not unlike the anguish and grief I experienced with the death of Kat’s twin brother, my son Cruz

NATURE | Unforgettable Elephants | A Mother’s Anguish | PBS

Kat: I grieve for the loss of my brother Cruz on this earthly plane, and cherish my connection with him in our spiritual togetherness. As an adult, I have become increasingly present with my feelings of grief, and with the emotional pain and sorrow of those who enter into the preterm birth experience.

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Do not surrender your grief so quickly Let it cut more deeply Let it ferment and season you As few human or divine ingredients can.– Hafiz of Persia

“Coping with Loss: Bereavement and Guilt”-Mental Health America:

Source: http://www.nmha.org/conditions/coping-loss-bereavement-and-grief

A child’s death arouses an overwhelming sense of injustice for lost potential, unfulfilled dreams and senseless suffering. Parents may feel responsible for the child’s death, no matter how irrational that may seem. Parents may also feel that they have lost a vital part of their own identity.

Living with Grief:

Coping with death is vital to your mental health. It is only natural to experience grief when a loved one dies. The best thing you can do is allow yourself to grieve. There are many ways to cope effectively with your pain.

Seek out caring people. Find relatives and friends who can understand your feelings of loss. Join support groups with others who are experiencing similar losses.

Express your feelings. Tell others how you are feeling; it will help you to work through the grieving process.

Take care of your health. Maintain regular contact with your family physician and be sure to eat well and get plenty of rest. Be aware of the danger of developing a dependence on medication or alcohol to deal with your grief.

Accept that life is for the living. It takes effort to begin to live again in the present and not dwell on the past.

Postpone major life changes. Try to hold off on making any major changes, such as moving, remarrying, changing jobs or having another child. You should give yourself time to adjust to your loss.

Be patient. It can take months or even years to absorb a major loss and accept your changed life.

Seek outside help when necessary. If your grief seems like it is too much to bear, seek professional assistance to help work through your grief. It’s a sign of strength, not weakness, to seek help.

Helping Others Grieve:

If someone you care about has lost a loved one, you can help them through the grieving process.

Share the sorrow. Allow them – even encourage them — to talk about their feelings of loss and share memories of the deceased.

Don’t offer false comfort. It doesn’t help the grieving person when you say “it was for the best” or “you’ll get over it in time.” Instead, offer a simple expression of sorrow and take time to listen.

Offer practical help. Baby-sitting, cooking and running errands are all ways to help someone who is in the midst of grieving.

Be patient. Remember that it can take a long time to recover from a major loss. Make yourself available to talk.

Encourage professional help when necessary. Don’t hesitate to recommend professional help when you feel someone is experiencing too much pain to cope alone.

Helping Children Grieve:

Children who experience a major loss may grieve differently than adults. A parent’s death can be particularly difficult for small children, affecting their sense of security or survival. Often, they are confused about the changes they see taking place around them, particularly if well-meaning adults try to protect them from the truth or from their surviving parent’s display of grief.

Limited understanding and an inability to express feelings puts very young children at a special disadvantage. Young children may revert to earlier behaviors (such as bed-wetting), ask questions about the deceased that seem insensitive, invent games about dying or pretend that the death never happened.

Coping with a child’s grief puts added strain on a bereaved parent. However, angry outbursts or criticism only deepen a child’s anxiety and delays recovery. Instead, talk honestly with children, in terms they can understand. Take extra time to talk with them about death and the person who has died. Help them work through their feelings and remember that they are looking to adults for suitable behavior.


Kathy: I regret not helping Kathryn and Cruz’s siblings with their grief processes. Overwhelmed with my own anguish, caring for Kat, working full time, I was profoundly engaged in a moment by moment effort to just make it through. I have since apologized, and want to thank my oldest child Jesse for stepping in to help me care for his brother and sisters.

Death of a child: Karly

The Luminous Light Beach Ceremony Carly Marie DudleyPublished on Dec 20, 2013

“It is with the greatest joy on this Saturday morning that I share with you all the film clip from our Luminous Light Beach Ceremony that we held back in November, to honour all of the babies and children that are no longer with us. We had 180 people come to share in this very beautiful sunset with us. As we tied ribbons to the peace branch we spoke messages of love to our children and the breeze took those messages out into the universe. Each person was invited to write their child’s name on a seashell at the beginning of the ceremony. During the ceremony we called out the names of over 300 babies and children. As those names were called we invited the parents to come forward to place their seashell in the sand next to the flame of remembrance. Next to the flame was a package of letters sent to me from last year’s prayer flag project and a list of names with messages of love from over 4000 families from all over the world. Once the family members and friends had placed their seashells in the sand, they were offered a handful of flower petals to take down to the ocean to give to the waves in an act of peace and remembrance. After the sun had set, that is when we began the bubble release. It was the most beautiful scene. Adults, teenagers, children and babies all surrounded by thousands and thousands of bubbles. Finally we gave out sparklers and glow sticks and the evening came to a close under the full moon and stars with families sharing their hearts on the beach with strangers. We covered the seashells with beach sand so that a part of our babies and children would remain at the beach together forever more. This was an evening that will be held in my heart and soul forever. I cannot thank everyone who came enough for without them, it would not have been possible. Please, when you have a spare 8 minutes, take some time out of your day and be a part of that beautiful evening.  With love, Carly Marie”

 

HEALTHCARE PROVIDERS

Our comprehensive efforts to identify and explore grief support for healthcare providers remains a frustrating and concerning endeavor. Our interviews with medical providers reinforce our understanding that a large portion of our Neonatal Womb Community does not have humane access to grief support resources. It seems to us to a large extent that grief in the healthcare, and especially in the physician and medical student communities, is denied, dismissed, buried, and our souls are broken. The Industry promotes, acknowledges the positive impact, and encourages provider “presence” with the patient population, but discounts the critical needs of the providers to be supported in being present with the wholeness of their own being. It is not possible to be fully present for someone else if one is not able to be present within their own being.

Nurses: We were able to identify several sources to support the grief process within the vibrant community of nursing professionals where the sharing of emotions such of grief are often encouraged and healing is supported. Nurses often mentor students in ways to seek grief support, acknowledge feelings, and function professionally within the healthcare environment.

“How Nurses Can Grieve the Loss of a Loved One or Special Patient”-by TAMMY RUGGLES, BSW, MA.-

Please Enjoy the Full Article: http://www.workingnurse.com/articles/how-nurses-can-grieve-the-loss-of-a-loved-one-or-special-patient

(10 ideas for touching the void: Below we summarize this helpful article):

  1. Listen to music. * Kat and I are both certified Zumba instructors, and we love Latin music. Neither of us speaks fluent Spanish (Kat speaks pretty good Portuguese). We acknowledge the healing capacity of music and how in some ways not understanding the lyrics of the songs frees us to connect fully with the emotion of the music and that connection allows us to acknowledge and say hello to the energies of our own feelings and senses. ”Words” are not required.
  2. Be alone with yourself
  3. Get out the photo albums
  4. Do something in honor of your lost loved one.
  5. Clear out the mementos, not the memories.
  6. Visit a support group in person or online.
  7. Help others through their grief.
  8. Clear out the mementos, not the memories.
  9. Visit a support group in person or online.
  10. Help others through their grief.

The New York Times – “When Doctors Grieve

By LEEAT GRANEK – MAY 25, 2012   (Leeat Granek is a health psychologist and a postdoctoral fellow at the Hospital for Sick Children in Toronto.)

Full Article: http://www.nytimes.com/2012/05/27/opinion/sunday/when-doctors-grieve.html?_r=0

In this article Leeat Granek reports “Our study took place from 2010 to 2011 in three Canadian hospitals. We recruited and interviewed 20 oncologists who varied in age, sex and ethnicity and had a wide range of experience in the field — from a year and a half in practice in the case of oncology fellows to more than 30 years in the case of senior oncologists. Using a qualitative empirical method known as grounded theory, we analyzed the data by systematically coding each interview transcript line by line for themes and then comparing the findings from each interview across all interviews to see which themes stood out most robustly”.

Psychologist Granlek stated “Our study indicated that grief in the medical context is considered shameful and unprofessional. Even though participants wrestled with feelings of grief, they hid them from others because showing emotion was considered a sign of weakness. In fact, many remarked that our interview was the first time they had been asked these questions or spoken about these emotions at all”.

Unacknowledged grief was described as “exactly what we don’t want our doctors to experience: inattentiveness, impatience, irritability, emotional exhaustion and burnout”.

In Summary the article proposes “To improve the quality of end-of-life care for patients and their families, we also need to improve the quality of life of their physicians, by making space for them to grieve like everyone else”.

A Poem – El Curandero –Rafael Campo

I am bathing. All my greyness— The hospital, the incurable illnesses, This headache—is slowly given over To bathwater, deepening it to where

I lose sight of my limbs. The fragrance, Twenty different herbs at first (dill, spices From the Caribbean, aloe vera) Settles, and becomes the single, warm air

Of my sweat, of the warmth deep in my hair— I recognize it, it’s the smell of my pillow And of my sheets, the closest things to me. Now one with the bathroom, every oily tile

A different picture of me, every square One in which I’m given the power of curves, Distorted, captured in some less shallow Dimension—now I can pray. I can cry, and he’ll

Come. He is my shoulder, maybe, above The grey water. He is in the steam, So he can touch my face. Rafael, He says, I am your saint. So I paint

For him the story of the day: the wife Whose husband beat purples into her skin, The jaundiced man (who calls me Ralph, still, Because that’s more American), faint

Yellows, his eyes especially—then, Still crying, the bright red a collision Brought out its perfect vessel, this girl, This life attached to, working, the wrong thing

Of a tricycle. I saw pain— Primitive, I could see it, through her split Chest, in her crushed ribs—white-hot. Now, I can stop. He has listened, he is silent.

When he finally speaks, touching my face, It sounds herbal, or African, like drums Or the pure, tiny bells her child’s cries Must have been made of. Then, somehow,

I’m carried to my bed, the pillow, the sheets Fragrant, infinite, cool, and I recognize His voice. In the end, just as sleep takes The world away, I know it is my own.

~~~~~~~~~~~~~~~~~~~~

Grief is only one aspect of Physician and Medical Student Suicide, but it may be a critical one. Although the article below is relatively long, it is very pertinent to the Neonatal Womb Community. Excellent medical care is critical to the health of the preterm birth community at large. Given the shortage of healthcare providers nationally and globally, the fact that the preterm birth community is large and preterm birth infant survival rates are increasing we need to support health and well-being of our healthcare partners. The comprehensive, thought provoking, and current Physician Suicide article below is one of numerous writings we reviewed that addressed the increasing necessity to provide appropriate, effective, accessible and safe/accepted support to the Global and National Healthcare Community at large, and to our Neonatal Womb partners Worldwide.

Physician Suicide

-July 28, 2016   Author: Louise B Andrew, MD, JD; Chief Editor: Barry E Brenner, MD, PhD, FACEP

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

Overview:

It has been known for more than 150 years that physicians have an increased propensity to die by suicide. It was estimated in 1977 that on average the United States loses the equivalent of at least one small medical school or a large medical school class to suicide.[1]   Exact numbers are not known. Although it is impossible to estimate with accuracy because of inaccurate cause of death reporting and coding, the number most often used is approximately 3-400 physicians/year, or perhaps a doctor a day. Of all occupations and professions, the medical profession consistently hovers near the top of occupations with the highest risk of death by suicide.

Sadly, although physicians globally have a lower mortality risk from cancer and heart disease relative to the general population (presumably related to knowledge of self-care and access to early diagnosis), they have a significantly higher risk of dying from suicide, the end stage of an eminently treatable disease process. Perhaps even more alarming is that, after accidents, suicide is the most common cause of death among medical students.

In every population, suicide is almost invariably the result of untreated or inadequately treated depression or other mental illness that may or may not include substance or alcohol abuse, coupled with knowledge of and access to lethal means.[2] Depression is at least as common in the medical profession as in the general population, affecting an estimated 12% of males and up to 19.5% of females.[3, 4]Depression is even more common in medical students and residents, with 15-30% of them screening positive for depressive symptoms.[5, 6, 7, 8, 9]  This is not an isolated North American phenomenon. Studies from Finland, Norway, Australia, Singapore, China, Taiwan, Sri Lanka, and others have shown increased prevalence of anxiety, depression, and suicidality among students and practitioners of medicine.[10, 11, 12, 13]

However, because of the stigma associated with depression in almost all cultures, which seems to be greatly magnified among medical practitioners, self-reporting likely underestimates the prevalence of the disease in medical populations. Indeed, although physicians seem to have generally heeded their own advice about avoiding smoking and other common risk factors for early mortality, they are decidedly reluctant to address depression, a significant cause of morbidity and mortality that disproportionately affects them. Depression is also a leading risk factor for myocardial infarction in male physicians, and it may play a role in immune suppression thus increasing the risk of many infectious diseases and cancer.[14, 15, 16, 17, 18, 19, 20, 21]

Because of their greater knowledge of and better access to lethal means, physicians have a far higher suicide completion rate than the general public. The most reliable estimates of successful completion of suicide range from 1.4-2.3 times the rate achieved in the general population. Although female physicians attempt suicide far less often than their counterparts in the general population, their completion rate equals that of male physicians and, thus, far exceeds that of the general population (2.5-4 times the rate by some estimates).[3, 4]

A reasonable assumption is that underreporting of suicide as the cause of death by sympathetic colleagues certifying death may well skew these statistics; consequently, the real incidence of physician suicide is probably somewhat higher than the prevailing estimate.

The most common psychiatric diagnoses among physicians who complete suicide are affective disorders (eg, depression and bipolar disease), alcoholism, and substance abuse. The most common means of suicide by physicians are lethal medication overdoses and firearms.[22, 23]

Depression in Physicians

Physicians are demonstrably poor at recognizing depression in patients, let alone themselves. Furthermore, they are notoriously reluctant to seek treatment for any personal illness. This may be especially true in the case of potential mental illness. A survey of American surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychological help. There was a strong correlation between depressive symptoms, as well as indicators of burnout, with the incidence of suicidal ideation. More than 60% of those with suicidal ideation indicated they were reluctant to seek help due to concern that it could affect their medical license.[24] Other studies in press and in progress reveal that this concern about regulatory intervention is a very common concern hampering help seeking for mental health issues.  In addition, other research suggests that 1 in 3 physicians has no regular source of medical care.[25]

Reluctance to recognize depression in a colleague is a tendency shared and imposed by other physicians, who may be well intentioned, habitually emotionally distanced from colleague/competitors, and/or feeling temporarily vulnerable themselves. Even when healthy, physicians find it difficult to ask for help of any kind. When they are depressed and feeling less than adequate, they find it even more difficult—and when they can bring themselves to ask, they sometimes find that the help they need is remarkably difficult to obtain.

To some extent, however, physicians’ reluctance to reach out is self-imposed. They may feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. Inquiring about another physician’s health can shatter this mutual myth of invulnerability, and volunteering support or assistance unasked may seem like an affront to a colleague’s self-sufficiency. Thus, the concerned colleague or partner may say nothing, while wondering privately if the colleague has become impaired.

Unconsciously defending against this painful vulnerability, partners or significant others may also fail to notice significant depression or withdrawal, attributing behavioral changes instead to stress or overwork. Nearly every article about a physician’s suicide contains a quotation from some close contact, occasionally a spouse, saying something like, “I never had any idea that he/she was suffering.”[26]Of course, many physician obituaries omit the fact that the “sudden death” was a completed suicide.

Depressed physicians who do reach out may find that they receive only limited understanding or sympathy from colleagues. There is no specialized training for a physician’s physician (as there is, for example, for the pope’s confessor). Most physicians either shrink from this role or perform it poorly.

For many experiencing depression, the early symptoms are physical. A physician unable to diagnose his or her own symptoms commonly feels incompetent. To admit one’s inability to diagnose oneself to another colleague is to admit failure. When this admission is met with avoidance, disbelief, or derision by a reluctant treating physician, it can only reinforce a depressed physician’s feelings of worthlessness and hopelessness.

Physicians find it painful to share their experience of mental illness with others and know that doing so is somewhat risky; therefore, published accounts of physician depression are very difficult to find. However, recent highly publicized cases of resident and physician suicides and subsequent sharing of experiences of depression by physicians[27] suggest that either the incidence of depression is rising, or we are beginning to be more able to admit and to address the immensity of the problem. 

Marriage is in most populations considered to be an effective buffer to emotional distress. This does not seem to be true for women physicians.[23]  It is believed that physician divorces are less frequent compared to the general population, but marital problems are common, perhaps in part because of the tendency of physicians to postpone addressing marital problems and to avoid conflict in general.[28] Marital problems, separation, or divorce can certainly contribute to depressive symptoms, which can increase the likelihood of suicidality if unaddressed.

Physicians are a “high control” population (along with law enforcement, lawyers, and clergy), and situations that decrease physicians’ ability to control their environment, workplace, or employment conditions predictably play a higher role in physician suicide than they do in lower control populations.[23]  The massive changes that have taken place in medicine in the past several decades, leading to increased workloads and regulatory requirements coupled with decreased ability to control income and patient safety and liability concerns also predictably lead to higher levels of stress, job dissatisfaction, burnout, and depression in physicians. 

Litigation-related stress can precipitate depression and, occasionally, suicide.[29, 30]The suicide note of a Texas emergency physician, written the day after he settled a malpractice case, read, “I hope that my death will shed light on the problem of dishonest expert testimony.”[31] Some physicians have completed suicide upon first receipt of malpractice claims, after judgments against them in court, or after financially motivated settlements foisted upon them by a malpractice insurer solely in order to cut the insurer’s losses. Any settlement in a malpractice case is by law reported to the National Practitioner Data Bank, which is yet another source of distress and stigma that can contribute to depression. 

Other physicians have attempted or completed suicide in response to employment discrimination relating to judgments or settlements or upon the realization that they are no longer able to practice because of discrimination by liability insurers who refuse to insure them because of past judgments or settlements or because of regulatory licensure investigations or limitations or databank reporting,[32, 33]  or in the setting of forced hospitalization or treatment for chemical dependency when a dual diagnosis has not been justified under medically accepted standards.[34]

Problems With Treating Physician Depression

Many clinicians are uncomfortable treating fellow physicians, especially in the realm of mental health.[35] The “VIP syndrome,” characterized by well-intentioned, but superficial or inadequate, treatment based on collegiality and concerns about confidentiality, can detract from the effectiveness of therapy.

Mental health experts who have studied physician depression and suicide stress that immediate treatment and confidential hospitalization of suicidal physicians can be lifesaving—more so than in other populations.[36] Yet, the specters raised by this approach—the fear of temporary withdrawal from practice, of lack of confidentiality and privacy in treatment, or of loss of respect in the community—are often major impediments that hinder physicians from reaching out in a time of crisis and seeking effective treatment.[32, 37, 38]

Physicians who have reported depressive symptoms (even those for which they are receiving effective treatment) to their licensing boards, potential employers, hospitals, and other credentialing agencies have experienced a range of negative consequences, including loss of their medical privacy and autonomy, repetitive and intrusive examinations, licensure restrictions, discriminatory employment decisions, practice restrictions, hospital privilege limitations, and increased supervision.[39, 40, 41, 37, 38]

Such discrimination can immediately and severely limit physicians’ livelihoods as well as the financial stability of their families. For this reason, well-meaning colleagues or family members who are aware of the depression sometimes discourage physicians from seeking help.

Licensure concerns

Medical licensure applications and renewal applications frequently require answers to intrusive questions regarding the physician’s mental health history and may be out of compliance with the provisions of the Americans with Disabilities Act (ADA).[42, 43, 44, 41, 45]

Most states have physician health programs that may or may not be associated with the medical licensing authority, and many have regulations that allow a physician enrolled in a physician health program who is compliant with treatment to check “no” on the mental health questions on licensure applications. However, physicians who are contemplating or in need of treatment are almost universally unaware of such “safe harbor” provisions.

Most physicians assume that any state agency or treating physician will share confidential information about them to the licensing authority.[46] Additionally, any lack of disclosure on an employment or credentialing application can be cited as grounds for termination or decredentialing.

Insurance concerns

Discrimination in obtaining insurance coverage is a common, but little publicized problem for physicians with mental illness. Health, disability, life, and liability insurance may all be denied to a physician who admits to depression.

Even if disability insurance has previously been procured, its use may subject physicians to repeated humiliating and invasive examinations by detached and dubious “independent medical examiners” for the insurer, whose motivation is to cut company losses. Many physicians affected by mental illness feel that insurers expect them to adhere to the standard prescription “physician, heal thyself.”

Self-treatment

Despite the protections afforded by law to citizens and other professionals who have disabilities, the potentially devastating effects triggered by a physician’s self reporting of depression may delay or, in effect, preclude appropriate treatment.

Although everyone knows that a doctor who treats himself or herself “has a fool for a patient,” we also know that most physicians treat themselves anyway, at least on occasion. This is especially likely when the physician believes that the consequences of seeking treatment may subject him or her to stigma, shame, or worse.

Because many states require reporting by other licensed physicians of a physician who may be suffering from a potentially impairing condition, physicians can be reluctant to seek treatment from colleagues, or from utilizing their insurance coverage, or even from using their own names when seeking treatment. A physician whose thought processes are clouded by depression and the anticipated consequences of seeking treatment for it may honestly believe that self-treatment is the only safe option. One analysis of physician suicide data relative to nonphysician victims revealed a much lower prevalence of antidepressant medication in the blood of physician victims, which is an objective indication of the truth that physicians do not receive mental health care in proportion to their need.[23] Too often, however, attempts at self-treatment are unsuccessful. Failure to obtain consultation and treatment for depression needlessly and significantly increases the risk of physician suicide.

Depression in Medical Trainees

Prospective medical students and residents are extremely unlikely to report a history of depression during highly competitive selection interviews. The prevalence of depression in these populations and in medical student and postgraduate trainees is unknown, but it is estimated to range from 15-30%.[5, 6, 7, 8, 9, 47]  After accidents, suicide is the most common cause of death among medical students. In one study, 9.4% of fourth-year medical students and interns reported having suicidal thoughts in the previous two weeks.[6]

One report has suggested that depression is not uncommon in pediatric residents (up to 20% self reported in 3 programs). This preliminary study found that residents who experienced depression may be as much as 6 times more likely than nonaffected controls to make medication errors.[48] Other studies have confirmed the association of depression with self-perceived medication and other errors.[49]Recently skyrocketing rates of burnout being reported among physician trainees and physicians have garnered attention[50] . Although burnout does not necessarily lead to depression, some of the symptoms are similar; and burnout probably contributes to the development or onset of depression in those who are predisposed. 

Stressful aspects of physician training—such as long hours, having to make difficult decisions while being at risk for errors due to inexperience, learning to deal with death and dying, frequent shifts in workplace, and estrangement from supportive networks, such as family—could add to the tendency toward depressive symptoms in trainees.

Harassment and belittlement by professors, higher-level trainees, and even nurses contribute to mental distress of students and development of depression in some.[51] Even positive workplace changes, such as translocations to secure further training or job advancement, can contribute to job-related stress. Suicide in medical trainees is most likely to occur just prior to beginning clinical rotations, or prior to or at the beginning of residency. 

A few schools are implementing programs to recognize and deal with depression and other stresses in medical trainees.[52, 53, 7, 54, 55, 9] The American Foundation for Suicide Prevention has created a video on the topic for physicians and other medical trainees.[56]

Education and Resources

Depression, like substance abuse, is not only more common in physicians than in the general public but also more readily treatable as a rule. This is because of physicians’ strong self motivation to continue successful pursuit of a professional calling, which is an important source of their self-esteem.

More education is needed regarding this disease and its disproportionate and needless toll on the medical profession, beginning in the earliest stages of physician training.[57] In addition, there is an urgent need to change the attitudes of those in health care (including those in the regulatory system), as well as the attitudes of the general public, toward mental illness. Such changes might encourage physicians to be more receptive to a diagnosis of depression and enable them to feel free to seek treatment without the fear of repercussion.

Physicians themselves need to be aware of the existence of physician health programs in nearly every state and province, which allow a physician who is compliant with treatment to avoid disclosing depression or other stable illnesses that do not interfere with ability to practice to licensing authorities.[58]  But they also need to be circumspect in dealing with these agencies, and to proceed with caution and full knowledge of the process before entering into it, because of the risk of being entailed into substance abuse programs, if no concomitant substance use disorder exists.[45]   

The American Medical Association had a 2009 directive from its House of Delegates to work with the Federation of State Medical Boards and Federation of State Physician Health Programs to study barriers to effective utilization of physician health programs, including assurance of confidentiality safeguards, and to educate members and others regarding the relationships between state licensing authorities and physician health programs. It is unclear what if any effect this activity has had on physician willingness to seek help for mental illnesses. However, the AMA and other organizations have realized that there is an emerging crisis of burnout in physicians and medical trainees, and are taking steps to address at least the burnout component. 

WARRIORS:

“Grief does not change you, Hazel. It reveals you.”

 ― John Green,The Fault In Our Stars

Grief is a dynamic emotion that calls for recognition in order to heal us as we evolve. Grief can freeze us, hide us, disguise us or even bury us. But grief can also empower us, strengthen us, deepen our capacities to love, connect and create! Life is about choices…….

Surf

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