It’s not enough to offer meditation and teach yoga. Institutions need systemic changes to protect the well-being of trainees, argues a researcher who has studied thousands of residents.
As I started my residency in June 2005 at Yale-New Haven Hospital, I found myself surrounded by some of the most impressive people I had ever met. My peers were brimming with ideas, idealism, and dreams of changing the world through medicine. Three months later, the picture of our class was very different. We were irritable, cynical, and thinking less about changing the world than getting through each shift.
Our experience was not unusual. As my collaborator and residency classmate Connie Guille, M.D., and I have learned from studying more than 20,000 trainees in the Intern Health Study, the rate of depression jumps 5-fold within the first few months of residency. In fact, about half of trainees meet criteria for depression at least once during their intern year — and rates of anxiety, burnout, and suicidal thoughts rise dramatically as well. As training continues, rates of depression remain elevated, with about 1 out of 4 residents screening positive for depression at any given time during residency.
The signs of stress are not limited to responses on a questionnaire. Telomeres, a cellular marker of aging, shorten 5 times as much during internship as during a typical year of life, a disturbing indicator of the toll medical training takes. What's more, the consequences are not restricted to physicians: Research also links compromised physician well-being to medical errors and poorer quality patient care.
If we are going to protect the health of trainees and their patients, we must make significant changes. Our attempts to teach residents resiliency and provide resources to promote well-being do not suffice. Instead, as research increasingly suggests, we need reforms at a much broader, systemwide level.
Our research points to possible solutions. In a 2019 study, we assessed more than 50 internal medicine programs, using feedback from residents and information from national databases. The results were eye-opening: We found large variations in depression rates, with some programs registering consistently high rates and others consistently low rates.
A key factor among low-depression programs was residents reporting that their inpatient rotations were a positive learning experience. Another was receiving timely and appropriate feedback from faculty. Both of these factors indicate that a focus on education, and specifically directed education from faculty, makes a major difference.
Our study also implicated long duty hours in compromised well-being. Specifically, we found that residents who worked more than 55 hours per week had increased rates of depression. Interestingly, telomere attrition also accelerated as weekly work hours increased.
Beyond the volume of hours, the type of work conducted during those hours is critical. Other research indicates that residents and clinicians spend twice as much time with computers as with patients, and greater time spent with a computer is associated with poorer well-being. More broadly, efforts to delegate administrative tasks to other care team members correlates with better well-being.
Finally, we have found that female interns experience a much greater increase in depression than male interns, and the biggest driver of this gap is work-family conflict. In fact, work-family conflict not only drives poor mental health but also career attrition, with almost half of women physicians stopping practice or practicing medicine part-time within 6 years of finishing residency.
As we look for solutions, research suggests several promising targets for reforms. Providing parental leave time for 3 or even 6 months can reduce work-family conflict. Similarly, providing daycare and creating more flexible schedules would help families with two working parents stay in the workforce. In addition, improving electronic health records and bringing on more medical assistants, scribes, physician assistants, and nurse practitioners can enhance care and reduce workload and administrative burden.
Faculty members also need to learn trainees' specific strengths and weaknesses and then provide thoughtful, specific feedback that truly supports their learning. Programs ought to encourage faculty to invest the time necessary to support learners and reward them for doing so. And, despite the difficulties this may entail, institutions need to reduce excessive work hours for residents, with a specific focus on minimizing the hours spent working with computers rather than patients.
In contrast to most current efforts that focus on increasing resilience in individual physicians, all of these promising reforms will require substantial investment of capital, personnel, and leadership. However, all signs suggest that such an investment is worthwhile. The effects of poor physician well-being on workforce attrition and decreased productivity cost health care systems roughly $15,000 to $20,000 per physician every year. Ultimately, investing in well-being of residents and creating better work conditions makes financial sense.
Most important, we have an ethical obligation to our learners to address the issues that contribute to their high rates of depression — and to the patients who may suffer as a result of their compromised well-being.
Srijan Sen, M.D., PhD, is the Frances and Kenneth Eisenberg professor of psychiatry at the University of Michigan Medical School. He is a principal investigator on the Intern Health Study, which has studied more than 20,000 interns for the past 12 years.
Editor's note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
This article was reprinted with permission from the Association of American Medical Colleges (AAMC).
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