It’s late afternoon at a busy medical clinic in Baltimore. Dr. John Allen sits at a small desk by the window. Pale yellow sunlight streams in. A can of diet soda rests on the windowsill. He scrolls through his patients’ test results on his computer screen and picks up the phone.
“Hi, it’s Dr. Allen, just wanted to go over the results of your recent hand X-ray. Good news – there’s nothing broken.”
Allen is in the second year of his Internal Medicine residency at the University of Maryland. He remembers his first year out of medical school, his intern year, was terrifying.
“It’s extremely intimidating for someone to look at you and say ‘Dr. Allen, or Dr. Such and Such’ and you ARE their provider,” Allen says. “They don’t realize that this may be your first day on the job and that you are not sure yourself that you’re their doctor.”
‘I remember feeling… like a huge failure’
This feeling of being an impostor is common for a new physician. After four years of medical school, intern year is the first time a doctor is actually on the job. As John gained experience, he took care of a patient who impacted him deeply.
“There was a very young gentleman who had metastatic cancer that encased his lungs,” he remembers. “And on the day that he ended up dying, I was at bedside with him and his nurse and his father for probably five or six hours and made sure he was comfortable. I think he died a peaceful and comfortable death, but at the same time, watching a dad who was in his 40s lose a teenage son to something I was powerless to stop… was very humbling. Because I think that you learn a lesson when you see something like that, that despite all the years of training, you obviously cannot fix what’s happening.”
There was another time, when Allen tried to save a patient’s life in the ICU. He was covered in the patient’s blood, doing chest compressions for almost half an hour. When the patient died, he went to break the news to his sister.
“She thanked me for trying so hard to save her brother’s life,” he recalls. “I remember just feeling at that time like a huge failure. And not feeling like I deserved any thanks or any praise for my efforts because they had not succeeded, and he had died, and he was a very young man.”
Experiences like these took a toll on Allen. “There was a lot of my intern year where, not realizing it at the time, where I think I was in a major depression, legitimately,” he admits.
The bigger picture
Allen is not alone. According to a recent study in the Journal of the American Medical Association (JAMA), one out of every three physicians in training experiences depression. This is about three times higher than in the general population. And the consequences are serious, including a higher rate of suicide in physicians. So, why?
“I think there’s a variety of reasons,” says Dr. Janet Serwint, the Vice Chair of Pediatric Education at Johns Hopkins in Baltimore. She’s in charge of training the hospital’s newest pediatricians, fresh out of medical school. “I think there’s a lot of perfectionism in medicine. And so I think there sometimes can be self-blame when there is an outcome that perhaps you weren’t really responsible for. You don’t have very much control over some of your schedule, some of the events that happen.”
When these pressures collide – perfectionism, self-blame, loss of control – it’s easy for new doctors to struggle. And to feel like they’re alone, especially if the culture is to keep pushing forward and not talk about it.
“It used to be really endorsed that if you were ill, you came to work and you were rounding with an IV in your arm as you’re getting IV hydration. I think and hope that those days are over,” Serwint says.
It has been a slow and steady shift away from those days. The JAMA study analyzed data from over 17,000 residents in different fields, dating back to the 1970s. It found that depression rates increased steadily as time passed. Imagine a graph with a line creeping upward, getting a little bit higher every year. This line – and the awareness that the line even exists – may be driving some of the change.
The role of fatigue
A focus on duty hours also plays a role, and has been studied this year at over a hundred residency programs around the country. How many hours in a row can or should a new physician work? What’s the right balance between learning as much as possible and being well rested?
Dr. Sandra Quezada, a gastroenterologist and assistant dean at the University of Maryland School of Medicine, remembers the fatigue.
“A lot of the reasons why I had those symptoms is strongly related to the sleep deprivation and feeling very, very tired.”
Now that Sandra has finished all of her training, she feels like herself again. But when she was a resident, she had little energy. She lost interest in activities she used to love. She just felt like someone different.
“And I learned a lot about myself during that time,” she reflects.” Mainly that by nature, I’m a happy, positive person, and I really lost touch with that in a lot in residency. And I do think that a lot of that had to do with just being exhausted.”
So Sandra did what many other young doctors do. She gave herself pep talks to get through the difficult times.
“I remember having to tell myself things in order to feel better and get through. So like telling yourself like, it’s going to get better, like next year will be better or next month will be better. And you have to keep telling yourself. And sometimes it really wasn’t.”
A shift to wellness
Even outside of the duty hour debate, educators like Janet Serwint want to usher in a more compassionate era of medical training. She’s part of a national group that’s studying this and polling residents on what they need to feel well.
“First of all,” Serwint proposes, “I think everyone should develop their own wellness learning plan. So say you’re involved with a really difficult situation. How do you get through that situation and then handle it afterwards? Some people maybe need to go vent to their spouse or a colleague.”
Others may need coping strategies like mindfulness, meditation, or exercise. There are system-wide changes, too – things that hospitals can do. Such as “making sure there’s a supportive environment at work. Not having a stigma about reaching out for medical health issues,” according to Serwint.
In fact, Serwint’s residents created a wellness committee to improve their learning environment, from supportive debrief sessions when a patient doesn’t do well to simply making sure work spaces are bright and functional. If a resident is already struggling with depression, there is help available. Hospitals have employee assistance programs. These used to focus more on physicians with debilitating illness like drug and alcohol addiction. Now, they offer counseling and treatment for doctors in even the earliest stages of depression.
“We can get people into resources very quickly. It is so important to reach out and not suffer in silence or in isolation,”
How is Allen doing now? “I’m doing a lot better,” he says with a chuckle. “I’ve learned a lot of coping skills and a lot of ways to sort of center myself and be more the person I want to be.” Allen did many of the things Serwint recommends. He opened up to family, his fiancée, and his friends and mentors. He reached out for help. And with educators like Serwint leading the way, more physicians can take care of themselves so they can take care of their patients.