What We Don't Talk About

Updated: Nov 16

When Dr. Lorna Breen died by suicide earlier this year, ripples of shock reverberated through the medical community. She could have been any of us. She was all of us. In the wake of her death her family described the horror she experienced as an Emergency Medicine physician in New York City at the height of the COVID-19 pandemic. (1)


The sheer volume of death witnessed by physicians and other healthcare workers during this pandemic would be unfathomable if it weren’t the reality so many of us are currently living.


The full impact of this magnitude of trauma on our physician workforce is yet to be realized, but it highlights a pre-existing vulnerability within our system: we don’t have space for physicians to process emotional trauma.





I can instantly recall the worst day of my medical career. It was a summer day during my third year of internal medicine residency when I was the MICU senior. It was the anniversary of my father’s death so I began the day in a place of grief and sadness. An hour into my shift there was a code on one of my patients. She had come in for an elective procedure and as a result of intraoperative complications was admitted to our ICU service.


We were not able to save her despite nearly an hour of resuscitation.


Her family was present during the code, crying and begging for her life in the hallway outside the room where we worked.


After time of death I excused myself to the bathroom where I cried too.


Fifteen minutes later I was responding to another life threatening patient emergency.

The specifics of my story may be unique, but my experience is not. We learn early on in our training that there is no room for our emotions. We learn to bury them and to move on to the next patient. The stakes for showing any emotion, let alone disclosing depression or other mental illness are exceedingly high in medicine. Not only is there stigma from colleagues and society at large, but there is concern about credentialing and licensure which require disclosure of mental health treatment on applications. This culture of silence is dangerous in a field that sees high rates of depression and suicide. (2)

Despite these stakes there has been a movement to push back against the stigma and make space for the conversation about the emotional trauma inherent to the work we do.


Many of the interventions being done by champions of physician wellness and suicide prevention are scalable to your own institution.

Schwartz Rounds is a program started by the Schwartz Center for Compassionate Healthcare that “offers healthcare providers a regularly scheduled time during their fast-paced work lives to openly and honestly discuss the social and emotional issues they face in caring for patients and families.” (3) Rather than review a case for its medical content, a case is reviewed through the lens of the human experience of those who were part of it. The rounds are multidisciplinary and include physicians, nurses, allied health professionals, and chaplains. Hospitals and other health care organizations can partner with the Schwartz Center to bring Schwartz Rounds to their institution. Feedback from organizations already participating report the rounds improve interdisciplinary communication, decrease feelings of isolation, and increase feelings of compassion in providing patient care.

Code Lavender is a crisis intervention tool developed by the Cleveland Clinic. The code can be called by any employee in response to a stressful event. The code team consists of chaplains, nurses, and volunteers who coordinate interventions such as debriefing, music therapy, meditation, and prayer. (4) These support people and services already exist in most hospitals and large healthcare systems. With buy in from leadership, a coordinated effort to maximize their skill sets for the support of our healthcare workers could be accomplished.

The Pause is a moment of silence after the death of a patient named and implemented by RN Jonathan Bartels. The pause is intended to honor the life lost and provide a moment of reflection before the medical team moves on with their next task. (5) Anyone on the healthcare team can initiate the pause and everyone present including the patient’s family can participate in the moment of silence. No formal process is needed for this one so it’s the easiest to put into your practice.


The next time you are part of the code team or present for a patient’s death you could start the pause by saying:


“Before we leave the room, let’s take a moment to honor their life and to recognize our efforts to try and save them.”

Innovations such as Schwartz Rounds, Code Lavender, and The Pause create hope that we are on the precipice of a shift in the culture of medicine. From one of stoicism to one of open, honest conversation about the trauma we experience in rendering care to patients. As with many aspects of our current healthcare system, this shift may be forced by the current COVID-19 pandemic. As our physicians have been inundated with death, the pandemic will necessitate a response that addresses this emotional burden if we are to sustain our physician workforce.



References

1 Watkins, A., Rothfeld, M., Rashbaum, W. K., & Rosenthal, B. M. (2020, April 27). Top E.R. Doctor Who Treated Virus Patients Dies By Suicide. Retrieved from https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html

2 Kalmoe, M. C., Chapman, M. B., Gold, J. A., & Giedinghagen, A. M. (2019). Physician Suicide: A Call to Action. Missouri medicine, 116(3), 211–216.

3 “Schwartz Rounds.” The Schwartz Center, 6 Feb. 2020, www.theschwartzcenter.org/programs/schwartz-rounds.

4 “Code Lavender: Offering Emotional Support Through Holistic Rapid Response.” Consult QD, Consult QD, 23 Jan. 2017, consultqd.clevelandclinic.org/code-lavender-offering-emotional-support-holistic-rapid-response/.

5 Durkin, Mollie. “'The Pause' Allows for Moment of Silence after a Patient Death.” ACP Hospitalist, 15 Jan. 2016, acphospitalist.org/archives/2016/01/q-and-a-the-pause.htm.

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