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RE: We Must also think about trainees and the role of culture

  • Amitha Kalaichandran, Resident Physician, University of Ottawa
  • Other Contributors:
    • Daniel Lakoff, Attending Physician, Healthcare Management & Leadership Fellow, Weill-Cornell Emergency Medicine, MBA/MS Candidate, Cornell University, Former Associate Program Director
13 May 2019

In response to: http://www.cmaj.ca/content/191/18/E505


The authors should be commended for covering an incredibly complex and salient topic in healthcare: that of physician suicide. We’re only beginning to discuss this openly and greater awareness is needed.

However, a conversation about suicidality in the medical profession would be incomplete without mention of recent surveys showing that up to 78% of trainees have experienced bullying and harassment (1). The evidence currently points to the learning environment in medical training as being a significant contributor to poor mental health (2). Doctors, by their very nature, are incredibly resilient (3), leading some to flatly state that “resident wellness is a lie" (4). We deal with life and death every day, and jump through many hoops to gain admission into the prestigious and competitive field. We are resilient.


Some factors behind the uptick in depression, anxiety, burnout, and suicidality are uncontrollable: the long work hours, high expectations, and poor sleep for instance. However, other factors are controllable: things such as the culture in the learning environment, prevalence of bullying and harassment, and the existence of enforceable policies to protect learners from psychological harm that ensue from these aforementioned factors as well as protection from reprisal when reporting concerns. We believe much of these latter factors can be ameliorated with sound leadership in programs: for instance choosing and supporting leaders who govern wisely, with integrity and compassion, and who are ideally elected democratically by the trainees they are intended to serve. As well, we believe that the cornerstone of an effective “physician health program,” must be freedom from any conflict of interest — personal or financial — that places them in the difficult position of serving two masters: the trainee and the program/medical school. We hope readers will be engaged in these issues and understand that the quest for physician wellness goes far beyond the basics of resilience training. Instead physician wellness must start with ‘boots on the ground,’ shifts in culture that have far more to do with organizational leadership, psychology and vulnerability. 


The profession is at a tipping point in terms of grappling with these issues. As millennial physicians who are committed to the issue of trainee well-being in the context of the learning and work environment (5, 6), who also believe wholeheartedly in the promise of medical training, we strongly urge trainees and staff physicians to be vigilant of the systemic institutional issues affecting you locally and seek leadership roles in order to drive change. Medicine, to paraphrase the words of Brene Brown, needs leaders who lead with courage, vulnerability, and compassion (7). We commend the CMAJ for helping shed light on the dire consequences that result if we continue to turn a blind eye.



Amitha Kalaichandran, M.D., Ottawa
Daniel Lakoff, M.D., New York City


1.Resident Doctors of Canada. 2018 National Resident Survey. Accessed May 10 2019. https://residentdoctors.ca/publications/national-resident-survey/nrs-2018/
2.Pereira-Lima K., Gupta R.R., Guille C.,  Sen, S. Residency Program Factors Associated with Depressive Symptoms in Internal. Medicine Interns: A Prospective Cohort Study. Academic Medicine 2018.  
3.Balme E., Page, L. Doctors ned to be supported, not trained in resilience. BMJ 2015; 351: h4709
4.Bernstein J.R., Resident Wellness is a Lie. February 2019. Accessed May 10 2019. https://in-housestaff.org/resident-wellness-is-a-lie-part-1-1319
5.Kalaichandran, A.  In America, becoming a. Doctor can prove fatal. Boston Globe,  March 15 2019. https://www.bostonglobe.com/ideas/2019/03/15/america-becoming-doctor-can...
6.Council of Residency Directors in Emergency Medicine. National Physician Suicide Awareness Day. Accessed May 10 2019. https://www.cordem.org/npsa
7.Brene Brown. Dare to Lead. Accessed May 12 2019. https://daretolead.brenebrown.com/

Competing Interests: None declared.
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