Part 3: You Can Have it All

From the May 19, 2023 issue of the Transformational Times

Part 3: You Can Have it All

Bryan Johnston, MD

In this essay, Dr. Johnston draws on a clinical encounter to show why he was drawn to his career in Family Medicine. He hopes graduating medical students will also find meaning and connections as they help other people throughout their careers ... 

 

 

“Not doing too good, Doc. I buried my cousin last week,” he said, slouching in his chair.

“What happened?” I asked grimly.

“It was sudden, I don’t really know what happened.” 

  

I murmured my regrets and a pause drifted over us. He and I had been meeting monthly for over a year and these moments had become part of our rhythm. He was still recovering from the loss of his son a few months ago, of an aunt last year. His tibia was still healing after a recent assault, his left orbit finally felt better after a pistol-whipping last year. His assailants had been after the most valuable thing he owned—the buprenorphine that felt like a firewall against the cycle of withdrawal and use he had clawed his way out of. 

  

Trauma within trauma, grief upon grief  

  

These moments matter to me because it is in them that I feel I can be of real use. To be of use, to me, is a concept marrying intrinsic and extrinsic needs along a trajectory of development. It is a way of seeking to understand and respond to needs you see that you feel called to and capable of meeting. It is a way to acknowledge what fulfills you, to build skills and experiences toward sharpening the impact you can make in doing those things. It can be a framework allowing you to infuse yourself into your work and also into humanity. 

 

Family Medicine and its proximity to meaningful relationships, behavioral health, and wellness, to community, and to health equity drew me in like whatever attracts songbirds to fly north in springtime. Over time, I gained skills in addiction medicine, trauma-informed care, social determinants of health screening and intervention, and system-level advocacy, always with a growing sense of being of use.

My patient had required all these skills and more, a high level of need but also a high level of mutual fulfillment in meeting that need. After I had found a pharmacist willing to dispense an early refill of buprenorphine after his last assault, he humbly thanked me and told me that he had never trusted a doctor before. 

  

 “How’s your family doing?” I asked.

“They’re ok, I talked to my father this morning and he’s taking it ok.”

“And how are you holding up?”

He laughed then shook his head. “It’s a lot, Doc. It feels like I’m surrounded by death.”  

 

We reviewed his support system, how he was coping with his suffering, checked his mood and screened for suicidality, then turned to the devastating impact of stacking grief and trauma. After months of coaxing, he had agreed to make a therapy appointment but had to miss it due to the funeral. He agreed to reschedule it.

“I know you’re a private person. But nobody can hold all that in. This is not a normal time you’re going through; this may be the hardest time in your life.” The buprenorphine was helping him, and he had not used. There were some positive things amidst the difficult parts, and we spent a few minutes focusing on that. “Be gentle with yourself right now,” I told him as we stood up.

“Ok,Doc,” he said, then shuffled off.  

  

I left the room feeling not sorrow, but deep well-wishes and gratitude for our relationship, for the intimacy we had shared, for the trust enabling support in this critical time. Above all, I felt that I was right where I needed to be -- at the intersection of skill, experience, and need; in short, that I had been of use. 

  

Medical learners often talk about what they want to do in the future

These conversations can take a short or long time, but most often avoid the core bits which underlie who we are, what we have come to understand about ourselves, and the connection we hope to have with others, with the world. In medicine we speak in symbols, we ourselves are symbols for who we are. I say I am a Family & Addiction Physician committed to health equity, and you can imagine several things about me. You might say you are going into Orthopedic Surgery, or Psychiatry, and others may intuit things about you.  

  

What I want to say is that you are a dynamic person, and it’s possible for the most important parts of you to come together in a future in which you are generating meaning for yourself and others by being of use in a way that is yours alone.  

  

Thank you for who you are and all the good you do now and in the future. And— enjoy the ride. 

 

 

(Patient details changed to protect identity) 

Bryan Johnston, MD, is a Family & Addiction Medicine Physician, and an Assistant Professor in the Department of Family & Community Medicine at MCW.  

 

 

Read this Issue. Your or Your Colleague’s Life May Depend on It.

From the 5/14/2021 newsletter

Director’s Corner

Read this Issue. Your or Your Colleague’s Life May Depend on It. 

Adina Kalet, MD MPH

This week, we focus on suicide and its prevention. Dr. Kalet urges you to read what is likely our most compelling issue ever of the Transformational Times, curated by Dr. Jeffery Fritz and the Kern Student Leadership group. You will learn a few things, be moved, and be better prepared to save a life …

The MCW-Milwaukee medical school graduating class of 2021 has suffered the loss of two of its cohort to suicide. This has been devastating for the families and close friends of these individuals. Their grief, profound and deeply personal it must be, and has been, treated with tenderness and respect for desired privacy. 

As new physicians, this class joins a profession where suicide is all too common. An estimated 300 US physicians take their own lives each year and the rates may be rising. It is likely that each of us have been, or will be, touched by suicide amongst our colleagues and friends. 

For many people who are contemplating suicide, prevention is possible. As colleagues, it requires each of us to be proactive, skillful, and brave in facing our own acculturated barriers to reaching out to others in times of despair. On a personal level, we must all learn to identify and skillfully intervene with friends and colleagues at risk, and vow to accompany those family members and friends who are left to deal with the grief and guilt that suicide leaves in its wake. It is good news that more than 90% of people who survive an attempted suicide never go on to die by suicide. Intervention and treatment save lives.

We also know that, in some cases, there is little that we can do. Some people are committed to ending their lives without intervention and offer no detectable warning or cry for help. With these deaths, we must care for the survivors, enact the self-compassion to digest and deal with our own thoughts and feelings, and develop meaningful ways to acknowledge the loss.  

What we know about suicide

Suicide is among the most common causes of death in those under 55 years of age. The rate of suicide has increased from 17 to 22 per 100,000 over the past twenty years, rising particularly among white and Native American men. Other Americans with higher-than-average rates of suicide are military veterans, people who live in rural areas, and workers in mining and construction. Lesbian, gay, bisexual, or transgendered young people have higher rates of suicidal ideation and behavior compared to their straight peers. There is a rising concern for adolescents who have been socially isolated during COVID-19. Those with mental health diagnoses, such as major depression and bipolar disorder, and those who struggle with alcohol or other substance abuse disorders are at increased risk. Because of their access to lethal weapons, people who live in homes with firearms are at higher risk. About 60% of firearms deaths each year in the US are suicides.

Systemic approaches to preventing suicide include cultural and institutional efforts that eliminate professional burnout and enhance wellbeing. This requires, as Dr. Cipriano points out in this issue, viewing suicide through a public health lens. Meaningful prevention of suicide on a population basis will require comprehensive approaches that strengthen financial safety nets and coping skills, promote connectedness, and enhance access to excellent mental health care. 

What to do when the person in front of you is suffering

Preventing suicide while in the presence of an individual who concerns you requires your active intervention. Learn to ask about suicidality. Be willing to remain present and keep the individual safe. Help the person stay connected to others and follow up. In this issue, our students describe their efforts to disseminate these basic principles. 

The experience of relatives and friends 

I find hearing that someone has killed themselves is always disorienting and unfathomable. While not ubiquitous, it is common for families to close ranks and feel both stigmatized and ashamed for a time. Traditionally, many cultures and religions have created a stigma around suicide although, as a result of work to raise awareness around these issues, most groups have faced down their stigmatizing actions. As one of this week’s authors, Toni Gray, points out, things have changed for the better through research, public awareness campaigns, and the compassion of mental health caregiving.  The key is to try, follow the lead of those who are grieving, and remember that they will be dealing with the loss for their lifetimes. 

Suicide in medical settings gets uncomfortably close

Suicide has touched my personal social circle a few times over the last years, including a teenager and more than one adult with loving families and seemingly rich lives. 

When I was just starting out in medical practice, it was a commonly held (and incorrect) belief that asking someone, especially someone who was desperately fragile emotionally, if they were considering killing themselves might “plant the idea in their head.” This approach likely cost lives. Now we know better. Many people who attempt suicide have seen a physician, usually not a mental health expert, in the weeks prior to the attempt. Physicians and healthcare workers in every specialty must understand their obligation to recognize and intervene.

In medical settings, I have noticed that suicides tend to happen in waves. A few years ago, a medical student, well known and loved by his peers and teachers and who had no known personal or academic troubles, jumped from the roof of a building in New York City. Soon thereafter, two other young physicians in our community died by suicide. Four senior physicians at a hospital where I have worked took their own lives over the course of a year; this was attributed to workloads of over 100 hours a week. 

MCW has been similarly touched. These are profound shocks for any educational institution and, despite having policies, protocols, confidential counselling, and employee assistance offices, deaths still occur. Each suicide is devastating. With each occurrence, we look for answers. We redouble our commitment to reach out if we are concerned about colleagues, friends or patients. We educate ourselves. We plan to simply ask, “Are you thinking about killing yourself?” and then commit to sitting and listening.  Each loss leaves the community diminished.

We hear the voices of people who have struggled

Like our anonymous student essayist, survivors of profound depression and grief often become so focused on their own suffocating isolation that they can see no other option. Shakespeare reminds us that, "Everyone can master a grief but he that has it." It falls to those of us nearby to accompany the person suffering, offering safety, connection, and help. As the student tells us, “As I am connecting with this other human, their logic and compassion towards me overpower the force of self-destruction.” We might be the one to save a life.

We are deeply grateful to those who contributed pieces in this issue. Students, staff, and faculty members who have struggled personally or vicariously through close relatives and friends, share their stories. We hear from Brett Linzer, a physician who, having experienced the loss of a number of colleagues and friends to suicide, as he faces his own burnout with the help of his loved ones. Although reluctant at first, he seeks the coaching that strengthens him with skills and support, enhances the joy he experiences in his work, and compels him to use his experience to work toward systems change for all of us. We get to know Kerri Corcoran, Student Behavioral Health and Resource Navigator in the MCW office of Student Services, who is committed to providing direct support for our students. MCW-Central Wisconsin students write about their work at self-organizing, with great creativity, to do suicide prevention work. 

This is a difficult, ongoing, and devastating problem that disproportionately touches us as physicians. We desperately want to do this right and welcome your experiences and efforts. 

I urge you to read this issue. You never know when it will be your turn to save someone’s life. 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.