“What could we have done differently?” | Thoughts on Institutional Forgetfulness

It is a question we often ask ourselves: “What could we have done differently?” Whether it’s when we’ve made a mistake, when an attending gives negative feedback, or when something unexpected happens, it helps us learn from our past. I find this to be an important question, and one that often guides me in medicine. Mistakes happen, and the process of a good medical education is full of trial and error. But how do we apply this learning to something bigger than a single person, like an institution or a school?

I visited a friend, also a medical student, in New York this past month. The day of my arrival, she informed me of some grave news: “A classmate of mine committed suicide this morning.” My heart ached for her school. I asked her if she wanted time and space to herself. She figured company would be good. Our lives paralleled one another– a year prior my school experienced a similar loss, and I tried to relate. But in those instances, it’s impossible to know exactly what a person is feeling.

As an outsider, I watched the tragedy of that morning unfold. My friend told me how their deans sent an email out to the school telling them someone had died but named no one. This caused a strange turmoil in her class given it could have been any member of their class that they lost. It was in whispers that many of her classmates found out who had passed and what had happened. The nameless email was just one of many things students felt the school had done wrong. Just hours later, school administrators held a student meeting. With just hours to process the day’s events people were already arguing, speculating the cause of this completed suicide, putting blame on the school and administration for unnecessary pressure the student likely faced. This meeting occurred while emotions were high; people were asking, “What could we have done differently?”

This event forced me to reflect on how my school handled its similar situation. I recall administration sending an email out, naming the passed student. Our school’s administration similarly held a meeting where we expressed our grievances with school stress, and need for mental health support. We were offered counseling, and made aware of the mental health resources available to us. Similar to my friend’s experience, students here were angry, upset with how the pressures we face can lead to things like this. But then months passed, and like lots of things in school, the passion that fueled concern for mental health and what had happened faded behind us.

I, too, asked, “what could we have done differently.” Though much can be said about suicide, and in particular physician suicide (here, here, here, and here), I wonder more about how we can institute change, and keep it relevant even after many of us have moved on. We shape our own personal knowledge by trial and error. But it’s difficult for us as transient four-year-students, to maintain an institutional memory of what we can do better. Administrators may persist, but those of us at the heart of wanting to create change are only temporary pillars trying to hold up this falling ceiling. We brainstorm ways to promote suicide prevention. We say, “this is how things should be.” But then we graduate, we move on, and leave future students who have not learned from our shortcomings.

In medicine, they say every patient is a teacher. In medicine you quickly realize people will die, you can’t save everyone. As healers we allow those we can’t save to become teachers, so that in the future maybe we can do something differently, and in the end save someone else. And in these two instances of losing our med-school colleagues, they have taught me the importance of mental health, that we need to address unnecessary stress, and we need to uncover and resolve systemic problems. But by evidence of persistent issues with higher rates of health-professional suicide, I’m not sure if institutions are remembering what they could have done differently. We need to figure out a way to remember what we have learned and not let time wear down these lessons.  And unless we fix this problem of institutional forgetfulness, we will keep asking ourselves, “What could we have done differently?” Unfortunately, this is a question of which I still have not found the solution.


With a heavy heart,
Bradford Nguyen

For those who wonder what we can do, suggestions from Jamie Riches, DO (http://blogs.jwatch.org/general-medicine/index.php/2016/07/what-is-resilience/):

“What can we do?

  1. Eliminate the word “burnout” from the lexicon: Not only does burnout minimize the severity of depression, detachment and (at extremis) suicidal ideation among healthcare professionals (HCPs), it implies that those suffering post-trauma have some inherent flaw or weakness that impairs their ability to remain functional. This mindset removes the onus from the system.
  2. End the stigma: Remove the question, “Have you ever sought treatment for any mental illness” from the job applications. We should encourage residents, physicians at all levels, and other HCPs to actively seek out cognitive therapy as we do vaccines or PPDs.
  3. Decide what graduate education is: If residents are primarily learners, we must protect their time and use it solely for educational (both clinical and didactic) purposes and not to provide underpaid labor to perform all tasks for which the hospital is at a loss, no matter how menial. If residents are employees, we must provide adequate pay for educational level, protect sick leave, and outline contractual responsibilities before enrolling in the agreement.
  4. Stop penalizing unwellness: Physicians and HCPs are as human as our patients. We are not immune to everything. There will be times when we will be ill, physically and emotionally. We will need time and space to heal.
  5. Structure the system in a way that minimizes fear of retaliation: If the person creating or enforcing destructive policies is the same person who needs to write the words “excellent candidate” on the letter of recommendation that carries the weight of your future career opportunities, your best and worst interests are one and the same.
  6. Embrace our own fallibility: Learn to be comfortable with imperfection. Let us have an equal respect for our accomplishments and failures. Employ mentors who set this example.
  7. Accept that medicine is not martyrdom: The work does not stop. Let it not deplete us. Let us take care of each other and ourselves and not give away everything that we need.”