https://jamanetwork.com/journals/jama/fullarticle/2722776

Comment; So good to hear an academic residency director honestly disclosing the “sordid past” of her genetic makeup! Will the state medical board attack her too?

A Piece of My MindJanuary 29, 2019

Breaking the Silence

Alisa Duran, MD1,2Author AffiliationsArticle InformationJAMA. 2019;321(4):345-346. doi:10.1001/jama.2018.22266

I’m sitting in front of a group of 30 internal medicine residents, having agreed to participate in a panel discussion for our residency program. The program directors recently incorporated a wellness curriculum, including content on mindfulness, meditation, and stress reduction. I am a part of an experiential component made up of willing faculty who are here to share their personal journeys with burnout, mental illness, and, in my case, substance use.

I have never spoken publicly outside of the cloistered rooms of recovery about my past struggles with alcohol. Physicians tell patients substance use is a chronic disease, like diabetes or cancer, but my past experiences of sharing my illness with colleagues have not always gone well. Some were supportive and kind, but there were also whispers, rumors, and quickly averted gazes in hallways. Some colleagues subsequently avoided me or have never treated me the same. The hidden message was clear: silence was better.

My eyes drift slowly over the audience. I am shaking and sweating, as are my co-panelists. I have been their program director, their preceptor in clinic, and I have overseen their women’s health rotation at an affiliated hospital. I admire these young physicians and in them I see a hopeful future and so much potential. As a medical educator, this inspires me and gives me courage to take the leap. If I can help even one of these residents, my discomfort will be worth it. Be brave, I tell myself. I am all in now. It’s time.

I take a shuddering breath as I introduce my true self for the first time to colleagues and trainees: “I have had the opportunity and privilege to work with many of you. Some of you, I don’t know at all. I am one of our faculty and I am a recovering alcoholic.” Breathe! I remind myself. “I’ve been in recovery for almost five years. I should add that I didn’t plan this. I didn’t wake up one day and decide to become an alcoholic. Let me tell you how I got here.”

I detail my journey, the struggles with anxiety beginning in medical school, the feelings of inadequacy and battles with perfectionism, feeling like an imposter among talented students, residents, and faculty; becoming a mom; finally achieving a long-standing goal of becoming a program director and the inevitable new challenges of trying to balance the demands of motherhood and running a large residency program; the self-imposed pressures to become a successful academician and never feeling like I was doing enough.

I describe starting to use alcohol to medicate my anxiety, and the end, the moment when I knew I needed help. I highlight the highs and lows of early recovery, the profound effect on my family and relationships, a divorce, and the important decision to put my health ahead of everything; the dawning realization that I matter and the decision to heal for myself and my young son. I describe the agonizing decision a year later to step down from my dream job and the fears that my medical career was over.

Fast forward to today; it’s different but my life and career remain fulfilling. I’m still a mom, again a wife, a teacher, clinician, and researcher. I’ve changed jobs. I’ve learned to say no to things, a skill I acquired out of necessity during recovery. I have “balance,” or as close to it as possible. I practice meditation, admittedly poorly, but I’ve tried to be open to something that I scoffed at early in my career. I work to be open-minded, willing, and honest, now essentials in my life. I work to be mindful and present. Some days are better than others, but it’s a process, and for that I am thankful. Would I change things? Probably not. It hasn’t been easy, but in the end, I am a better human being and physician. I’m grateful for the opportunities I have each day to help others struggling with mental illness and addiction, both inside and out of the clinic. I’m more humble, empathetic, and kind.

I sit and listen with admiration as others share their personal struggles. Similar themes emerge: anxiety, depression, perfectionism, eating disorders. The residents are laser focused, several have tear-filled eyes, some appear to be deep in thought. Many nod their heads as they follow the dialogue. You can hear a pin drop. Finally, it’s over. The silence weighs heavily on me. Can I take it back?! Images flash in my mind of a cartoon character, arms flailing to retract the word bubble escaping from her mouth. What have I done? I see my fears reflected in the eyes of my co-panelists. My heart is heavy with regret.

Then the residents begin to share their own experiences. Many stories are like those of the panelists. They talk and hug. There are tears and laughter. The humor is contagious and healing, a balm extinguishing my own worries. They speak poignantly about the power of vulnerability and its importance. We are grateful to have given them the space to share their thoughts and fears.

Afterward, my colleagues and I debrief with the residents. Why did we do this? Because the “collective we,” physicians, are dying. People who appear to have it all together are suffering in silence. This year at our medical school, without warning, we lost two individuals. Nationally published rates of suicide among physicians are more than twice that of the general population.1,2 On average, 300 to 400 US physicians die by suicide every year.3,4

As I reflect on my personal experience, I think about my hesitancy when I initially got the invitation for this panel, the cautionary advice from family and friends, and the dawning realization that this is bigger than me. I HAVE TO DO THIS. I share my fears after early revelations to a close group of colleagues, and the rumors that ensued and the ultimate decision to break my silence years later. We must have these conversations and create an open dialogue among our community. Our learners need to understand that they are not alone. As clinicians, we are never going to get past the stigma of these conditions if those most affected do not share their journeys, and these conversations need to start somewhere. This requires some of us to take the first uncomfortable steps.

We need to foster a culture of vulnerability and a safe space where these conversations can continue; that starts with a small group of people being willing to share, to be authentic and vulnerable. This is me, for better or worse. Reach out and talk to people. We are here for you. Heads around the room nod in unison, the relief on the faces is telling and palpable.

Thank you, they say.

The silence is broken.Section Editor: Preeti Malani, MD, MSJ, Associate Editor.Back to topArticle Information

Corresponding Author: Alisa Duran, MD, 1 Veterans Dr, Minneapolis, MN 55417 (duran012@umn.edu).

Conflict of Interest Disclosures: None reported.References1.The American Foundation for Suicide Prevention. Healthcare professional burnout, depression and suicide prevention. https://afsp.org/our-work/education/healthcare-professional-burnout-depression-suicide-prevention/. Accessed December 28, 2018.2.Schernhammer  ES, Colditz  GA.  Suicide rates among physicians: a quantitative and gender assessment (meta-analysis).  Am J Psychiatry. 2004;161(12):2295-2302. doi:10.1176/appi.ajp.161.12.2295PubMedGoogle ScholarCrossref3.Center  C, Davis  M, Detre  T,  et al.  Confronting depression and suicide in physicians: a consensus statement.  JAMA. 2003;289(23):3161-3166. doi:10.1001/jama.289.23.3161ArticlePubMedGoogle ScholarCrossref4.Moutier  C.  Physician mental health: an evidence-based approach to change.  J Med Regulation. 2018;104(2):7-13. doi:10.30770/2572-1852-104.2.7Google ScholarCrossref

Dr. Raymond Oenbrink