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Dark Thoughts in a White Coat: Burnout and Depression in US Medical Residents

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“Haunted” by Jacqueline Huynh, MD. Dr. Huynh’s art was selected as part of the Expressions of Clinician Well-Being, a National Academy of Medicine initiative that promotes awareness of physician burnout or resilience through art.

I was somewhere into the twelfth hour of my twenty-eight hour shift when I met a newly diagnosed lymphoma patient and his lovely family in the emergency department. After hearing his symptoms and completing an examination, I explained to them that I was going to be admitting him in to the hospital. They asked the usual fanfare of questions about what the next steps would be. But then, I was thrown a curveball. His sister, with an eager and happy smile across her face, simply asked me: “Is this what you dreamed you wanted to be?” A question I had been asked many times before.

If it had been maybe 12 months earlier, when I was still a green-horned intern, I would have answered without hesitation or falsehoods. I’m not sure if it was because I was on my ninth consecutive day working in the hospital. Or, since my pager was going off every few minutes, I hadn’t yet found time to eat that day. Or, it could have been because he was the twentieth some odd patient I’d seen that long, unrelenting call day. But I found myself choking back tears and shoving down an intense feeling of sorrow. I forced a fake smile across my face to mirror hers and responded with an emphatic “yes.” For the first time in my short career, doubts were implanted in my mind regarding my career choice. I was experiencing burn out.

Training as a resident physician in the United States is an extraordinary undertaking. You’re expected to train for a life-long career as a physician in just a few grueling years. The way physician training programs are currently designed leads to heightened feelings of emotional exhaustion, depersonalization, and a sense of low personal accomplishment — the exact three elements that psychologist Dr. Herbert Freudenberg used to characterize a work-stress he called “burnout” in 1974. A lot of a resident physician’s day is spent doggedly trying not fail at simultaneously attempting to be a good clinician/surgeon, problem-solver, leader, mediator, scribe, scholar, sibling, child, friend, parent, and spouse. Residents are juggling so many responsibilities that it is easy to see how a study from 2006 showed that residents prior to the start of their training had a self-reported burnout rate of 4.3%, which increased well over 10-fold by the end of their first year in residency to 55.3%. Regardless of residency specialty, the rates remain high.

A 2004 study showed the average burnout rate is 50% among resident physicians, with rates has high as 75% in obstetrics-gynecology residents, 63% in internal medicine residents, and 50% in dermatology residents. Depression is also rampant among resident physicians, as an NIH-funded study estimated that about 21–43% of resident physicians have depressive symptoms or depression. This is significantly higher than the 6.7% of US adults with diagnosed depression. The current work conditions are significantly better than even the 1990s, but despite implementing work-hour restrictions and improving awareness of mental health issues amongst residents by the Accreditation Council for Graduate Medical Education, suicide is the second most prevalent cause of death amongst residents.

The World Health Organization (WHO) has recognized that there are risk factors in the work environment that impact a person’s mental health and can cause symptoms of mental disorders, harmful use of alcohol, or drug abuse. Many of these identified risks are unsurprisingly deep-rooted in the current residency training program model: high work loads, lack of control in work-related decisions, low status or respect in the workplace, poor financial compensation, inflexible work hours, and wretched home-work interface. These common elements are seen throughout the healthcare work environment, which is why medical students, practicing physicians, and nurses are all uniquely vulnerable to having difficulties coping with work-life imbalance and finding time to focus on personal health and welfare. There are mixed reports and studies that have failed to highlight the best route to tackle this overwhelmingly complex issue. But with well over 130,000 resident and fellows in over 10,000 programs nationwide, junior level providers are aptly positioned to unlock a real solution.

Medical residents uniquely serve in a position as leaders of multidisciplinary teams composed of learners in every phase of their career. We daily interact with medical students, ancillary staff, and attending physician. With such vast and diverse outreach, we have at our disposal the perfect opportunity to engage in free and open dialogue about mental health in graduate medical education and healthcare. We are perfectly positioned to spark a national conversation about resident physician burnout, which would allow us to serve as advocates for change: creating enforceable laws to better regulate work-hours, encouraging practices that focus on resident well-being, reinforcing the importance of humanistic medicine, and authoring hospital policies that improve the quality of the work and training experience for all healthcare workers.

Without a movement to help voice the magnitude of this issue, I fear the statistics regarding physician mental health will only worsen, and stories like mine will continue to go untold. Like the great American activist, Maggie Kuhn once said: “ Leave safety behind. Put your body on the line. Stand before the people you fear and speak your mind — even if your voice shakes. When you least expect it, someone may actually listen to what you have to say.”

Chioma Udemgba, MD, is a current Internal Medicine-Pediatrics resident training at Tulane University in New Orleans, LA. I have no conflicts of interest to disclose. I will be attending the National Academy of Medicine on May 2, 2018 via webcast. The meeting is aimed at providing an arena for the public to participate in the action collaborative. They have scheduled expert panels on issues related to clinician burnout, resilience, and solutions to promote well-being.

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