When Sean Wilson needed to make his first life-or-death decision as a doctor, it wasn't his medical school training he called upon. It was his time spent in Canada's infantry that helped him.
Originally from northern Ontario, Wilson had just moved his family to Montreal to start work as a resident family doctor, a junior physician learning the ins and outs of a specific medical discipline.
"It was a struggle," he says of the transition from medical school to residency.
Fortunately, the Armed Forces, rather than medical school, had taught him how to stay calm under pressure using "resiliency skills."
But most new doctors don't have a military background that comes with special training in resiliency, and many are overwhelmed by the responsibility of caring for sick patients in busy hospitals. That stress leads to burnout and depression.
A 2015 review in the Journal of the American Medical Association found one in three residents is depressed, and that physicians experience higher-than-average rates of suicide.
That looks set to change, however, as many Canadian hospitals and medical schools adapt psychological training originally developed by the U.S. Navy SEALs to help soldiers stay calm under fire, similar to training Wilson received during his time in the Canadian Forces.
- High percentage of Sask MDs at risk of burnout, survey says
- Medical students face 'alarmingly high' rate of depression, study finds
The usefulness of the training reflects the similarities that exist in the worlds where doctors and soldiers work.
"In both fields you are given enormous amounts of responsibility to make decisions that have life-and-death consequences," says Wilson.
Doctors and soldiers are "always under a level of ongoing stress with bursts of really stressful situations" that they have little to no control over, says Scott McLeod, deputy surgeon general of the Canadian Forces.
McLeod recognized that doctors might benefit from the same training as soldiers and in 2014 approached Resident Doctors of Canada, which represents 9,000 junior doctors in Canada.
"The similarities are very apparent; the inevitability of stress, difficult situations, sleep deprivation and the need to perform under those conditions," says Dr. Christina Nowik, a resident in obstetrics and gynecology at Queen's University in Kingston, Ont., and past president of RDoC.
"Something about the health-care environment makes doctors sick," she says, citing studies that show as many as 75 per cent of Canadian resident doctors are burnt out.
Nowik worked with the Forces to adapt soldier training for doctors. The final product is a four-hour course delivered by peer trainers.
"People who take the training say: 'It's about time,' " she says.
The Canadian Forces began searching for ways to develop the psychological strength of soldiers in 2002 when the Canadian government committed troops to the war in Afghanistan.
'Your life is dependent on staying calm and making appropriate decisions while under stress.' - Scott McLeod
"We wanted to help the men and women deploying to Afghanistan manage their stressors," says McLeod.
"Your life is dependent on staying calm and making appropriate decisions while under stress."
Lt.-Col. Suzanne Bailey, a social worker with the Canadian Forces, was tasked with building such a program and found the "resiliency training" used for the U.S. Navy SEALs.
SEAL candidates with strong resiliency skills were less likely to flunk out of training, and scientific studies showed improved SEAL performance in underwater and land-based operations after training was completed.
The training consists of two key pillars.
Participants are taught to spot where they fall at any given time on a mental health "continuum" or colour-coded stress scale.
Four zones — green, yellow, orange and red — represent escalating levels of stress and dysfunction and include recommended actions that doctors can take to reduce their levels of stress.
The second pillar consists of four skills that can control the body's hormonal response to stress, with the goal of overriding fear.
'These are tools you can implement right away.' - Dr. Christina Nowik
The skills seek to bypass the brain's amygdala — the emotional response centre that can stimulate a fight-or-flight response — and favour the frontal lobe, where rational decision-making occurs.
"These are tools you can implement right away," says Nowik, who now teaches them to doctors. "They are very practical."
The most popular tool, she says, is "tactical breathing," where deep breaths are held to activate nerves in the diaphragm, which then slow neurochemical release in the brain.
Other skills prepare physicians for stress, conditioning the amygdala to respond to acute situations as though they were routine.
RDoC has piloted its four-hour resiliency course at Dalhousie University in Halifax and at the University of Calgary.
"It really resonates," says Nowik, whose next stop is McMaster University in Hamilton.
"The general feeling is that it's about time we started talking about this," she says.
'Focus on individual factors'
Last year, the Ottawa Hospital decided to adapt the military resiliency course for its caregivers.
"We identified a need to address emotional exhaustion amongst doctors and nurses," says clinical psychologist Kerri Ritchie, who has piloted the training among a group of staff working with patients who are dying.
"The environmental factors are hard to change so we need to focus on individual factors, and that's where resiliency comes in," says Carolyn Lajoie, a psychiatrist and director of faculty wellness at the Ottawa Hospital, who works alongside Ritchie.
"We are in a really interesting time in medicine; increasing patient volumes, economics, patient expectations and changing technology … [and] these changes are having a major impact on physician stress."
Back in Montreal, Wilson remembers his deployments as a soldier.
"With this generation of combat veterans, discussions around mental health are extremely commonplace, but discussions around physician mental health still remain very taboo," he says.
Wilson is trying to change that. He's spearheading resiliency training at McGill University in Montreal.
"Affecting any cultural change is difficult, doubly so in medicine, but I think we are pushing in the right direction."