Reasonable Accommodations

How my residency class came through when I needed it.

I've written before about having bipolar disorder. Today's post is about how my colleagues proactively helped me stay well. Welcome to The Frontier Psychiatrists.

I attended a residency program with a unique system for allocating responsibilities. Instead of having senior residents make a schedule, they let each class own the responsibility of deciding who would cover which shift.

Today, Facebook's algorithm reminded me of the week before my 13 years of bipolar disorder stability and episode-free wellness ended. It had everything to do with sleep:

I've written about sleeping bipolar disorder before, but today's article isn't about referencing data.

That week of night float, we didn't get the schedule ourselves in the second year, the first week of three. In general, during my psychiatry residency, that lack of sleep was the beginning of my mental health deterioration. If you have bipolar disorder, it's a really good idea to sleep at night. It's an even better idea to sleep at night and be awake during the day at regular times. A reasonable accommodation, if you have the disability of bipolar disorder, is to have a call schedule that does not lead to brain implosion. One of the issues, of course, is that hospitals need to be covered overnight and on the weekends, and my psychiatry training program had a hell of a lot of service requirements. Some training programs handle this by not having enough trainees to do all the coverage, so they have to hire people who are not still in training to stay up all night. A lot of learning happens during those overnight shifts, but for someone with bipolar disorder, they are lower-risk options than learning in the middle of the night.

In my third year of psychiatric residency, in July, the very beginning of the medical New Year, my depression—which had started to rear its head with that first-night float the year prior—got so bad I had to walk into a psychiatric emergency room for myself. I spent eight days as a psychiatric inpatient in a hospital affiliated with the hospital in which I did my training. In retrospect, it would've been better for everybody if they had not forced me to go to an in-network and thus in-system hospital. This was the choice of the system health plan; my outpatient psychiatrist of many years, in his day job, was the inpatient psychiatry attending at another psychiatric unit in New York City. Which my insurance wouldn’t cover, because they didn’t own that hospital.

My simple advice to every health system is to develop a swap agreement with another health system when it comes to psychiatric care: if your resident needs psychiatric hospitalization, please, God, let them go to a hospital system that isn't yours. Privacy is essential for getting well for many.

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Medical trainees are especially vulnerable, decreasing the chances they will seek help. This delay makes things worse. Keep in mind the suicide rate among residents is absurdly high:

In the fall of 2010, among the 109 survey respondents (46.4% response rate), the rate of suicidal ideation during family practice residency was 33.3%, the rate of suicidal ideation with a plan during residency was 18.1%, and the rate of suicide attempt during residency was 2.9%.

One of the issues is that we don't talk about it. Everybody having this experience assumes they're going through it alone. I write articles like this one so that we all know otherwise.

One of the startling things about these statistics is that residency, in the above example, family medicine residency, is only three years. That is not a lifetime rate; it happens in one high-risk period. Program Directors and training institutions should plan for this much more proactively than I believe they do—that being said, Training Director has never been a job I've had. I don't know how much planning for this inevitable situation they do.

After that one week, and a few more after that, and my at-the-time-fiancé leaving me because depression is terrifying… the story (along with my mom’s diamond ring walked-off-with) landed in the gross New York Post…no, I am not kidding…I returned to work. Thanks to great psychiatric care and sleep, I was well again.

My classmates welcomed me back with the following news—they covered all my on-call shifts while I was out, and they had pro-actively decided I'd only ever work weekend days ever again. Some of them liked nights better anyway, they assured me. It would be just as much work—but only when I could still get a good night’s sleep. This was gracious and kind and is the behavior I'd advocate for anyone with a colleague going through a difficult time. My colleagues picked up the slack and then some, and I am forever grateful.

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This is in the era before transcranial magnetic stimulation was a treatment for me! I didn't know that my deliverance could be as simple as it has been ever onward! In the near future, fMRI-guided neuromodulation treatment, robust walking, and other novel interventions will be the standard of care.

To all the trainees out there? Be kind to each other, and if you have bipolar disorder? Sleep at night.