Policies

Notes on fellow and faculty member well-being.

The information below is excerpted from this wellbeing guide.

Introduction

The very nature of forensic pathology places fellows and faculty members at risk of burnout and depression, threatening the well-being of individuals. No other field of medicine sees the depravity and cruelty of humans. At the same time, forensic pathology exposes human beneficence and bravery. Fundamentally, forensic pathology assures the final testimony of each human is done with respect, equality, and dignity. Practitioners need mental resources and a foundation of well-being to flourish in life and in the profession. Self-care is an essential component of professionalism and high-quality patient care; it is also a skill that must be learned and nurtured in other aspects of residency training.

Definitions

Burnout: Long-term exhaustion and diminished interest in work. Dimensions of burnout include emotional exhaustion, depersonalization, and feelings of lack of competence or success in one’s work. Burnout can lead to depression, anxiety and substance abuse disorders.

Resilience: The ability to withstand and recover quickly from difficult conditions or situations. During training, fellows may face difficult patient care, educational or personal events which have the ability to negatively affect their Well-being. Decompressing after such situations, through conversation with peers, mentors or family, and self-care activities, can increase resilience.

Well-being: Refers to the state of being healthy, happy and successful. Well-being may be positively increased by interacting with patients and colleagues at work, being intellectually stimulated and by feeling that one is making a difference/helping. In addition, self-care activities, including exercise, getting plenty of rest and connecting with others, is beneficial.

Policy

Fellows’ physical, psychological and emotional Well-being is of vital importance to UND Forensic Fellowship Program and our ACGME-accredited training programs. Fellows are encouraged to lead healthy lives and make healthy choices that support them in their personal and professional growth. To that end, we provide the following strategies to support trainee health, well-being and resilience:

UND Employee Assistance Program: Confidential and free counseling services include relationship issues, emotional health issues, drug and alcohol issues, workplace issues, financial issues, legal issues, wellness, educational programs, and 24/7 telephonic crisis counseling.
The UNDSMHS GME Office is a safe place where Fellows can ask for and receive help with various needs including academic counseling, coaching, and mentoring.
UNDSMHS and UNDSMHS GME Office provides program directors with resources to educate faculty and trainees about the symptoms of burnout, depression and substance use and their avoidance.

Other resources and support

Fellows have access to healthy food and snacks at the forensic office and break-rooms with refrigerators, microwave, coffee and tea at UNDSMHS.
Fellows have reduced rates for wellness activities and memberships at UND Wellness Center, Choice Fitness, the “Y”, and multiple smaller gyms in the Grand Forks area.
The new medical school, where the fellows have their offices, has wide corridors and stairs, encouraging walking and healthy activity.

Program Support

Paying attention to fellow schedules to look at work intensity and compression factors.
Training in situations prone to stress-creating, i.e. death notification, speaking with families, court and depositions.
Allowing fellows to attend medical, dental and mental health care appointments, including those scheduled during work hours.
Educating fellows and faculty about burnout, depression and substance use, and their avoidance.
Teaching and nurturing self- care practices, an important component of professionalism and high-quality patient care.
Providing a respectful, professional and civil environment that is free from mistreatment, abuse or coercion.
Learning self-care is an important component of professionalism and patient care, and fellows and faculty have a responsibility to themselves and to their patients and programs to ensure that they are fit for work through behaviors such as: Proactive selfcare, and modeling of healthy lifestyles and behaviors for patients, students, and colleagues.
Impairment recognition and notification, either from illness, fatigue and substance use in themselves, their peers and other members of the health care system.
Time management surrounding clinical assignments. Case loads are monitored and will not exceed the national recommendation of 250 in the fellowship year with a minimum of 200 cases and targeted number of 220 cases, allowing ample time to learn in depth.
Lifelong learning
Performance improvement indicator monitoring. Participation in the quality review and quality management activities of the office are an integral part of the fellowship training. Cases are reviewed in a spirit of performance improvement, not on retaliation, bullying, or punishment.
Reporting duty hours, patient outcomes and clinical experience (such as case logs).

Additional Resources: UND GME policies via website

Campus Resident Advocate
Concerns and Complaints
Resident Work Environment

Stress and wellness considerations for forensic pathology

Interpersonal relationships and communications: Interpersonal communication, delivery of upsetting news, and difficult conversations are core to the practice of forensic pathology. The fellow will be encouraged to communicate directly with their peers, supervising faculty, and mentors regarding any concerns. The fellowship program director will be available to address any specific complaints or concerns fellows may have. If issues arise regarding one of the faculty or residents, the program director will directly discuss the complaint with the appropriate party. The program director will ensure that the individual who raised the grievance will not be explicitly named whenever appropriate and is not subject to retaliation during the rotation or in the written evaluation. Suppose a complaint against the program director or a fellow complaint is not addressed to their satisfaction. In that case, the fellow will be encouraged to communicate the issue to the UND GME officer. There is an opportunity for anonymous reporting at the GME office level. Finally, residents can report concerns or complaints anonymously through the ACGME website.

Stress and Mental Health in Forensic Pathology: Throughout the history of forensic pathology, many individuals were exemplary in supporting pillars of social justice, standing for truth when political forces were filled with opposition, and assuring the final testimony of each human is done with respect, equality, and dignity. No other field of medicine contributes and measures both the depravity, the bravery, and beneficence in humans. Our past is not perfect, as human practitioners fail on occasion, but we can be proud of the shared heritage and principles: to seek the truth of every case and carry the torch of the many giants before us.

Courage, Bravery, and Heroes for Truth and Justice: Forensic pathology, through the bravery and honesty of Dr. John Edland, first exposed prison and police actions at Attica. Ridiculed and disbelieved, he stood firm and truthful, exposing the reality of the Attica “riot” and the ill-planned, poorly executed takeover and aftermath. Many, perhaps most, lives were lost unnecessarily and the quickly spun excuse of prisoner atrocities committed against guards was totally rebuked by objective findings at the autopsy. John Edland stood firm in his findings and in doing so, and at great personal cost, he forever changed the dialogue of police, prisons, and reform. Forensic
pathologists and anthropologists are routinely called to work in war zones, identifying and providing testimony to genocide, and exposing war crimes to the world. This is an honorable profession we are in. Each day we make a difference in the lives of people we meet and it ripples to those we do not meet. All of us stand for principles and unbiased truth-finding using all the skills we have to accomplish that goal. Most of our careers will have major cases that are felt long after official closure. A few of us may be privileged to stand with the giants before us – speaking the truth, respecting our decedents, and telling their tales against fabrications of convenient political forces. We will provide some basic skills and tools. The guidance for truth must come from within.

Your Presence and Practice: People do not select their medical examiner as they would a family doctor, pediatrician, or other health professional. Yet, you will become an indelible part of that family’s history for better or worse, likely more than the family’s other health professionals. Most people have some spirituality, culture, and practices intrinsic to their being that do not include a medical examiner. Yet, when the need is greatest for comforting rituals, you appear with no expectation or knowledge of that family. Death, especially sudden or violent death, comes unexpectedly, without preparation, goodbyes, or opportunities for thanks and shared joy of recollection. Often you are the one that notifies the family; you are the one they will ask to make sense of the unimaginable. Few people tell us about this part of the job. It takes a toll. But it can also bring meaning, satisfaction, and joy as we use our skills as physicians and humans to stand for truth, equality, and justice. Few other professions, and no other branch of medicine, provide a practitioner with this degree of human connection and communication. Always have respect for the families of decedents. Be kind and treat them as you want your family to be treated. Do not talk down to them and give them time to ask questions and grieve. Try and be at the same level, eye to eye. Ask about cultural or family expectations and accommodate when possible. Understand the basic death rituals and practices in your area but expect and welcome individual variation.

Spectrum of practice: There is no other area of medicine, and very few professions, that have as broad an exposure to cultures, people, and traditions, good or bad. Everyone will die and, in some aspect, will fall under forensic pathology, Many expected, natural deaths receive minimal or no involvement but most offices deal with these as numbers at least. The bulk of the cases actively investigated will come from all walks of life, all races, cultures and creeds. Few professions offer the opportunity to learn and interact with this broad range of people. Forensic practice exposes you to people at their greatest stress and grief. You often meet people on the worst day of their lives. Be culturally and racially aware, control the situation with respect and kindness, do not expect thanks or gratitude. Give people the time they need but assure your safety and your teams safety in unstable situations - either from physical danger or emotionally unstable situations.

Respect for all: In this era of awakening and growth about race, culture, sexuality, and gender equality, our society is working toward better understanding and equality for all. It is a difficult conversation with backsteps and hesitations, however, within the profession, we can advance toward this goal by remembering and practicing basic courtesy and respect. From this, we will be rewarded with growth and knowledge about people we did not know as well while we are improving our ultimate job.

Fairness in our work and judgment: Forensic pathologists and investigators must mindfully be aware of our inherently human biases within our culture and not use our cultural context and vision to judge others.

Fundamentals: Our offices are or should be acting independently from any other government function. Forensic pathology and death investigation are not the police or judiciary and this should be stated (if true) to our clients and their families. Although we work with both law enforcement and the judicial system constructively and honestly, we do not answer to them nor act on their behalf. We work for the truth surrounding the deaths we investigate to tell the story of our patient - the decedent. The decedent gets our respect and attention. We are respectful of the decedent’s family and others involved in the investigation.

We play fairly and equally, showing the same level of empathy and respect to a witness in a jail cell or homeless shelter as you would for a witness in the finest of homes. We take care of ourselves and our people, mentally and emotionally. We support co-workers, treat all members of the team respectfully, recognize stress, and help each other.

Some of the general resources above and notes on the importance of mental health in death investigation and forensic pathology are extracted from M.A. Sens and R. Hughes, Diagnostic Pathology: Forensic Autopsy (Elsevier, 2021).