Here at Becker's Hospital Review we write about "physician burnout" pretty frequently. Physicians are stressed out, overworked and disenchanted with medicine. We've written about how to combat burnout with organizational leadership, lean strategies and even mobile apps. Yet while medical institutions, physician groups and healthcare administrators are working to combat burnout, the problem persists.
Perhaps the larger issue at hand is that stress and burnout can lead to something that doesn't get enough airtime — depression. According to the American Foundation for Suicide Prevention, anywhere from 300 to 400 physicians commit suicide each year. Among male physicians, the suicide rate is 70 percent higher than other professions. Among female physicians in the U.S., it's 250 to 400 percent higher.
Studies have shown these issues crop up early in the medical career. Medical students have 15 percent to 30 percent higher rates of depression than the general population, according to AFSP.
For more perspective on this issue, we spoke with Srijan Sen, MD, PhD, associate professor in the department of psychiatry at the University of Michigan in Ann Arbor. Dr. Sen is the principal investigator of "The Intern Health Study," a longitudinal project that examines the stress and mood of about 3,000 interns each year. He hopes to better understand stress and depression among interns to improve their environment, as well as research the genes and peripheral biological predictors involved in the development of depression under stress.
Here Dr. Sen discusses the factors, both negative and positive, of the intern environment and why it is so critical to address mental health issues in medical professionals to provide better, safer healthcare.
Note: Responses were edited lightly for length and clarity.
Question: What initially interested you in studying interns' mental health?
Dr. Srijan Sen: I did my PhD in genetics and moved toward studying the interactions of genetics and stress in depression. All the studies were retrospective because no one could predict when people are going to be stressed, just like no one can predict a divorce, or that someone will get fired. I was starting [an] internship myself with a cohort of new doctors. In May and June, we were all interested and had hobbies, and three months later we were depressed, stressed out and breaking up with our significant others. It was a model where we could predict that healthy, well-adjusted people were going to be stressed.
For more personal reasons, a couple friends — a family friend and a friend from medical school — were going through training to become physicians and one completed suicide and one had a suicide attempt. It happened for multiple reasons, but partially from the stress of residency. I saw multiple colleagues going through training and it seemed like a really inhumane way to treat people.
Q: Why did you choose to focus on interns specifically instead of all physicians? Do we see similar prevalence of stress, anxiety and depression among medical professionals at different stages in their careers?
Dr. Sen: Definitely there are stressors at all stages of physicians' careers, but issues are most acute during internship. Hours are high and at least, if we are talking broadly across specialties, highest during the internship year. It's also the first time physicians have real patient care responsibility; anecdotally interns talk about that as a major stressor. They are making life and death decisions for the first time and don't know if they have the adequate training to handle it. More senior residents undergo a lot of stress and doctors in practice have a lot too, but it first emerges in full extent in internship. That's what I wanted to understand and capture — how people adjust to the stress of being a physician, when they first become a physician.
It's also a relatively universal experience for all interns, regardless of whether they are going to be neurosurgeon or a radiologist. It's a common experience; whereas later on, the stressors of being a surgeon are different than those of a dermatologist or a pediatrician.
Q: What external factors influence stress, anxiety and depression in interns most? How much do shift-length, sleep and environment affect interns' mental health?
Dr. Sen: All those factors certainly play a role, as you mentioned. People also come into it with personal factors that influence how they will be affected by stress. From our work, the most important external factor is the number of hours. There is no real relationship between hours and depression below 55 per week. After that, the relationship gets really strong, exponentially, so that the more hours an intern works above that level, the more depressed they get. The ones that work 110 hours a week are almost all depressed.
Shift length may not be as important as we thought. The American Council of Graduate Medical Education put in a rule in 2011 to restrict the maximum length of a shift from 30 hours to 16 hours for interns with hopes to improve conditions for interns and patients. Studies seem to indicate it is having the opposite effect. People are committing more errors and not sleeping more. The overall number of hours is the same, but shift length has been made shorter.
There's a phenomenon called "work compression" where interns are asked to see more patients in the same amount of time, so they are able to devote less time and less mental space to patients. Quality seems to suffer.
Another big external factor is the large and growing workload among training doctors. Turnover and length of stay is going down, so more patients are shuffling through, but the same numbers of interns are doing the work with restricted hours. That really increases the stress of each intern in the hospital.
Q: Based on your work, what do interns say is positive about residency environments? What is most negative?
Dr. Sen: Well, there are different cultures in different residency programs. Medicine is quite hierarchical and getting negative feedback and signals from the residents above you or attending physicians can be difficult. Getting yelled at or blamed for things, especially things that are not under your control, is something residents say increases their stress. In our study we let interns write free text that we analyze qualitatively and that's a common theme that comes up as a negative factor.
Positive factors include getting positive reinforcement when things are working well and positive feedback from patients, especially when a patient does well. The interns who did well often remembered an occasion when a patient expressed gratitude. Setting up some mechanism for patients to show their gratitude and being able to thank the doctors, especially at that early stage in doctors' careers, could serve as a wonderful protective factor. People really remembered positive feedback from patients more than I expected. Similarly, positive feedback from superiors when they do something well actually makes a big difference.
Q: What kind of biological or physical factors are predictive of depression or stress in interns?
Dr. Sen: They are similar to biological factors in other people who are depressed and under stress in general. We found a couple genetic factors and genetic variation. It doesn't seem to matter if you have the risk factor at the baseline when the interns are not under stress. But the interns with the risk gene get 20 percent to 30 percent more stressed during internship. There is clearly a genetic component to stress, but we are still in the early stages of finding and identifying specific genes.
Q: How common is it for interns and residents to seek help for mental health issues?
Dr. Sen: Not very common. About 15 percent to 20 percent who meet criteria for depression seek formal help, so a very small percentage. Among the reasons why seem to be not having enough time — during hours that most therapists and psychiatrists see people they are working — and a surprisingly strong stigma around mental health issues amongst doctors. It's the fear if they got help somehow it would reflect badly on them, and their colleagues and program directors and bosses would think less of them.
Q: Some medical schools have launched wellness programs to help interns better manage mental health, and ACGME is working to find solutions to physician burnout and stress. What has changed in the culture of medicine that is making us now realize these are critical issues?
Dr. Sen: The issue is probably not new, it is just with tracking and data, we are realizing that there is a clear and strong link between mental health and wellness of physicians and the care that they provide to patients. So we know that if doctors are depressed and burned out and sleep deprived, that is going to translate into poorer care for patients. That has made the issue of physician mental health a bigger priority for ACGME and other administrative boards.
Also, just the general culture has changed outside of medicine and work-life balance and phrases like that, that didn't exist 30 years or 100 years ago when system was devised, are now part of our culture. The first residents lived in the hospital — that's why they are called residents. Now that's not practical because people rightly feel like they should have outside lives. We're seeing it in the press with expositions on the Amazon work culture in The New York Times and articles on the importance of paid sick leave and parental leave. It's a big conversation amongst the age that most interns are at — 25 year olds. Larger culture is influencing the conversation in medicine.
Q: Is there anything else you feel medical professionals and healthcare administrators need to know about mental health and medicine?
Dr. Sen: I made this point earlier, but there is clearly a strong link between medical professionals and the health of patients. Investment in making the culture and workplace more conducive to having healthy physicians might take some money initially, but evidence indicates that will pay off in better healthcare for patients, less errors and less cost. That is why all of us, whether we are physicians or not, will benefit if we improve this culture as much as we can.
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