Karissa LeClair '21 with her father, Robert,
at her White Coat Ceremony.

Personal Tragedy and the Mental Health Burden on Doctors in Training

During her first year of medical school, Karissa LeClair and her family experienced an unexpected loss. In this essay, she writes about her experience in the context of a culture uncomfortable with talking about personal wellness and mental healthcare and how that culture is changing.

By Karissa LeClair '21

KARISSA ARE YOU THERE OH GOD
THEY'RE DOING CPR ON DAD

I almost hadn't answered the phone. I was exhausted, studying for an upcoming endocrine exam, when my younger brother's name lit up the phone screen late one Saturday night. December 3, 2016.

Knowledge can be a burden. Prior to medical school I spent a year working as an EMT and was therefore familiar with the statistics of cardiac arrest. The depiction of CPR on television is an optimistic hoax—in reality, 90 percent of people who experience an out-of-hospital arrest don't survive. I had worked two codes a few weeks prior, picking up a shift at my old job during Thanksgiving break of the first year of medical school. That night after my shift, I spent nearly an hour regaling my father with stories of my heroic efforts at work that day. Neither patient survived.

My brother was in a panicked frenzy. As I tried to process his words, these statistics and experiences buzzed in my head, a neon DANGER sign toward which we were suddenly hurtling at 90 MPH. He repeatedly shouted the same question:

IS. DAD. DEAD?

The remainder of the night was a blur. Somehow, the phrase "[insert name here] is a medical student" is enough to gain entry into the exclusive club of healthcare. I was placed on the phone with the EMT driving the ambulance as they raced my father to the hospital, a horde of EMS providers performing CPR in the back. The EMT only shared snippetsof details, but I clung to them—concrete facts I could rationalize. Witnessed arrest. Good. That likely meant CPR was started rapidly and he may have a shot at emerging neurologically intact. V-fib. Good. A shockable rhythm. Minutes from Portsmouth Hospital. Good. I would always prefer to transport critical patients to this hospital rather than lower-level centers nearby.

He died anyway. I found this out a tense hour later, berating someone who refused to tell me the news overthe telephone.

The human body is a miraculous physiological marvel, knowing exactly how much it can take before shutting down to protect itself. Shock (n). A term we use colloquially, but also to describe specific processes that the body undergoes to compensate when it realizes it has been critically damaged. Parts of that night remain lost, but I remember feeling disconnected as I heard myself reply to the news—sounding more like an automated voicemail than a child who had just unexpectedly lost a parent.

Thank you for letting me know ... I am two hours away please tell my mom and brother and make sure they are both okay ... I will see you soon please leave a message after the beep.

I felt nothing. But my bags needed to be packed. I would likely be at home for a while, and I couldn't wear the Dartmouth sweatshirt that I was currently wearing to a funeral. It wasn't black. My roommates, who had been present for the entire saga, stared at me with concern once I hung up the phone, their eyes asking what they could do and also looking like they wanted to hold me. I told them I was fine, but I needed help packing my bag.

Hospital glow. Waiting room. More people trying to hold me. I push through crowds of family members to fall into my mother's arms. The disconnected fog lingers as members of the care team speak with us—offering us mini water bottles, as if our issues could be solved by a small dose of hydration. I pay close attention to how they deliver bad news, as we had recently covered that in our clinical skills course. I take notes on what not to do.

Something that rarely gets talked about is the amount of paperwork involved when someone dies. Oh, so sorry your world has been upended, could you please sign on the dotted line to clear me of any liability? My mother transferred healthcare proxy into my name, allowing me to coordinate the process of organ donation. I spend two hours on the phone negotiating like a black-market organ dealer. Yeah sure. Take his eyes. The one-of-a-kind blue eyes that made me feel like everything in the world was okay. Go ahead. Do I sign right here?

I took a month off from school to spend time with my family. The medical school was incredibly accommodating, allowing me to keep up with classes from home. We spent the holidays just the three of us—my mom, my brother, and I, hoping that if we held each other tightly enough we could keep our sanity from slipping out through the cracks in our souls. And then the New Year passed. And then it was time to go back to school.

Karissa LeClair '21, an experienced emergency medical technician, partnered with fellow med student Nicholas Valentini D '13, MED '20, Dartmouth-Hitchcock's Lyme clinic, and Upper Valley Ambulance to create a pilot project in which paramedics use downtime between emergency calls to visit patients in rural Orfordand Piermont, NH.

Photo by Kata Sasvari

My wonderfully-supportive classmates throw a party when I return. I'm thrilled to see their smiling faces, but cringe realizing this is a literal pity party. I immerse myself in classes, presuming a busy mind has little room to wander. One marginally-better-than-awful month passes. I discover that if I participate in enough activities, learn enough things, and never spend any time alone, it's almost as if nothing changed at all.

Despite the body's miraculous ability to adapt to stress, sometimes even this operating system experiences processing malfunctions. In healthcare we are acutely aware of this, as we would be out of jobs if the human body was a perfect system requiring no maintenance or repair. I had planned to grieve in a controlled and scheduled setting—but my buried experience begins to seep out.

I would learn in psychiatry the following year how to diagnose a panic attack. But in my first clinical exposure once back at school, I unexpectedly learn what one felt like. We are assigned to work with inpatient nurses as part of an interprofessional teamwork module. I sign up to shadow a late-night hospital shift. For some reason, hospitals have always been my safe harbor—a haven where I would eat lunch, study, or people-watch. But now the wires in my head are fraying. Things are beeping. The hospital is glowing.

Our second patient, an elderly woman, angrily reminds the nurse she has a DO NOT RESUSCITATE order. Last time they did CPR on her it hurt, and she doesn't want that again. I stiffen. As I fixate on the patient talking, I wipe my sweaty palms on the bed rail, wondering why I suddenly feel so faint. My heart feels the need to prove how well it can work by surging its rate and contractility—a hospital-induced stress test. I hear the blood pumping in my eardrums and swear the monitor beeps faster and faster. The stethoscope around my neck chokes me and the white coat I was so excited to wear that day feels like a straitjacket. I want to scream, but instead I step out of the room. When the nurse finds me, I tell her I had been sick that week. She lets me go home. I convince myself I had been sick that week. Everything is fine.

But anxiety breeds anxiety. When someone in your life dies unexpectedly, you gain a newfound awareness of your own mortality. Every sensation—it could be that you drank too much coffee, or that you're in rapid supraventricular tachycardia that could decompensate at any moment. In a morbid twist of fate, I had been in the OR shadowing trauma surgery earlier on the day my dad had died. The thought of an operating room becomes my worst anxiety trigger.

I have wanted to be a surgeon since I was old enough to form coherent sentences. Yet this goal becomes diluted. By my second year, I have become adept at avoiding clinical situations, particularly those involving any interaction with the OR. Ironically, I become a leader of the surgery interest group, yet manage to avoid the OR for over a year. I begin to tell people that I'm considering other career options.

This story was hard to vocalize and took a long time to share. But I don't share my experience to call attention to the fact that I'm unique in deserving grace through this journey. Rather,I feel an obligation to write this for the exact opposite reason—experiencing personal tragedy or trauma in medicine is so much more prevalent than we acknowledge.

Since my dad passed, several classmates have experienced the same loss. I have sat beside friends as we learn about diseases of childhood, knowing their child suffers from the condition I am taking notes on. Last fall, our medical school suffered a traumatic wound when a beloved classmate died without warning. That same term, the second-years covered stages of grief in psychiatry class, highlighting testable points even as they personally struggled with this grief—one seat in the room glaringly empty.

These are just the visible wounds.

In highlighting my experience with personal tragedy, I hope to not undermine the mental health struggles not due to particular pinpoint-able events. Life is a series of small insults and sometimes the brain gets sick and breaks on its own. While medical school has been an amazing and fulfilling experience, it is also a demanding ordeal with unmatched potential to breed mental illness. These conditions are far more prevalent than the majority of us would let on.

Last year during our own pass through psychiatry, several wise classmates realized it would be a glaring oversight to wrap-up the subject without addressing the elephant looming in the lecture hall. One cold December night, we convened in Chilcott Auditorium as part of an informal, student-run gathering. Classmate after classmate shared their own experience with mental health struggles—from hospitalizations to medication to recovery. For the first time, I opened up about my newfound anxiety. I wasn't planning to say anything. I sat in the corner for just that reason. But suddenly I was talking, and everyone was listening, and when I was finished sharing my struggle, it was no longer just my own. It may have been the dimly-lit atmosphere or the cheap wine we drank from Solo cups, but that night we felt bonded, each breathing a sigh of relief to know we weren't alone.

Have I talked to a therapist? Yes. Probably not as much asI should, but I'm in medical school and I'm busy and it's hard. However, I've also found the most therapeutic interactions are often informal ones with mentors and peers. My first time back in an OR was with my closest friend by my side—a trusted classmate who knew the hurdle it posed for me. I felt sick that day. But once we stepped into the cold operating room, we were laughing, and we were learning, and I felt okay. This self-prescribed exposure therapy has been an active effort over the past several months—supported by the surgical mentors I know so well, creating a setting in which I feel at ease. I am always aware of my environment, but I find surgery so fascinating that time flies and anxiety melts away.

As medical students and future medical professionals, several of us undergo these personal crises and respond in the manner most natural to us: we pack our bags. While we may be completely devastated, we can't just be paralyzed with emotion—because who else is going to handle this? And this quality wonderfully and uniquely equips us to care for patients. If my family member was in a medical crisis,I certainly would want them under the care of a provider who was able to maintain composure and not be overwhelmedby personal emotion. Having this personal experience also allows for a certain empathy when caring for suffering people. But, at the same time, we are kicked in the face every day with reminders of our own trauma and are expected to put it aside for the sake of patient care. I can speak from personal experience that it is impossible and unhealthy to pack your bagsand then bury them in the back of the closet.

My argument is not for more structured time to talk about our feelings. In medical school, there are numerous venues to talk about our feelings and then to reflect on how we felt about talking about our feelings. Instead, I advocate for a culture shift. We need to foster an environment in which we feel comfortable talking about our mental health, and on the administrative end, we need to remove the logistical barriers to caring for this health. I share my story to encourage others to work at addressing and de-stigmatizing the elephant in the lecture hall.

Other American medical schools have begun assigning each first-year student their own mental health provider. While this may not be the perfect system for every individual, it does create an important paradigm shift—turning mental healthcare into an opt-out standard rather than an opt-in accommodation. Just like the rest of the human body, our minds can be affected by illness and therefore require regular maintenance and upkeep. At Geisel, faculty and staff are working with psychiatrists to establish appointment openings outsideof normal business hours, so that third- and fourth-year students on rotation can access regular treatment. Another initiative, proposed by students in their clinical years, is the concept of personal choice wellness days in place of strictly-defined sick days. Providing patient care in a setting where I am clouded by personal emotion or performing at half-capacity has greater potential for harm than the risk of passing on my viral URI. However, many students fear the consequences of asking for accommodations if this avenue has not already been normalized and established.

Ultimately, the most effective solutions will be those shaped by peers working in conjunction with an administration willing to navigate the logistics of this challenge. Because it is inevitable that as future healthcare professionals, we will continue to step up and pack our bags in the face of tragedy, trauma, or crisis. The crucial variable will be establishing adequate resources and support to help unpack these bags once the dust has settled.