By: Rachel Goossen, MD
In May 2019, headlines of a study out of University of Michigan hit the lay media: “New Doctors’ DNA Ages 6 Times Faster Than Normal in First Year.” Using DNA samples submitted by medical residents across the country, the Intern Health Study measured telomere length before and after residents completed their intern years. Loss of telomere length has been associated with morbidity, mortality, and even depression. A clear association was made in the study between the degree of telomere shrinkage and the reported number of hours the interns worked each week. The study’s senior author, Srijan Sen, MD, PhD, concluded that interns should focus “as much as they can on their mood, sleep, and stress-relieving activities.”
In a 2016 publication on the prevalence of depression among medical interns, Sen found that 35% of respondents screened positive for clinically significant depression. Depression during intern year was found to correlate negatively with job satisfaction and positively with medical errors. Amongst their conclusions:
“Destigmatization of mental illness among medical trainees and making screening and treatment for depression more accessible are important steps to addressing this issue. Proactive, resilience-based strategies also may help interns retain the enthusiasm that brought them to the medical profession in the first place so that they may emerge from training as capable, confident and forward-looking practitioners.”
I’m fairly certain I participated in this study. My rapidly shrinking telomeres and the ongoing trauma of my medical education has rendered my short term memory essentially useless, but I do recall, at some point during my intern year, submitting a DNA sample to some study that I’d thought had some merit and wondering if I would regret it later. I appreciate Dr. Sen’s dedication to bringing attention to the unhealthy and inhumane aspects of medical training and I echo his call for change. I do, however, feel there is a glaring question that has not yet been adequately addressed: Why is this job so depressing?
I had the good fortune to be raised in a family where mental health was anything but stigmatized. When I went to my parents with stress or conflict they felt was beyond their purview, I was met with an enthusiastic, “Why don’t we get you scheduled with a counselor?” As a result, I’ve had a string of (mostly) wonderful therapists come in an out of my life over the past few decades. Engaging in good therapy during times of need has given me better insight, self-awareness, and certainly better coping skills. Any of my friends, family, or patients will tell you a I am an enormous proponent of therapy—therapy for everyone!
I actually didn’t find myself in need of therapy during residency until about halfway through intern year when my infant daughter suffered an episode of anaphylaxis that left me feeling traumatized. I started seeing Dr. H soon after and was so grateful to have the established clinical relationship and support system when several other significant challenges arose in the months that followed.
Towards the end of a particularly grueling month in the MICU, during which I was completely isolated from the residents in my program, not to mention my friends and family, I attended a badly needed counseling session. Aside from the 30 hour shifts and post call rounding, I found myself really struggling with the emotional toll of watching fellow humans in horrifying states of illness, actively suffering from pain I could not take away. I told Dr. H, “I feel like I just can’t watch any more people die. This is really depressing.” Dr. H looked at me and said, “That is an appropriate reaction to this situation. This is an exceptional circumstance.”
This thought has resonated for me more than any other throughout residency and was a tremendous gift from Dr. H to me. Her words were a permission that we, as medical trainees, are not given at work. She normalized my reaction to a completely abnormal experience. This acknowledgment–that medical training can be toxically abnormal–and the permission to react appropriately to it, was revelatory and completely new.
Medical education, by definition, will always include sick patients. There will always be death and pain. Bearing witness to these dark and uncomfortable parts of the human experience is depressing—depression is an appropriate response. In contrast, it is the trainees who do not experience an emotional response to these experiences that should provoke concern. The unavoidable emotional toll of medical training cannot be adequately countered by a free lunch in the cafeteria, a social event held on hospital property, or a required lecture on meditation. Residents need time to sleep, time with family, and time for exercise. There is no calculus in the present structure of medical education to make this possible.
Residents do not just need to exercise more, practice mindfulness, or “make time for wellness.” Studies that focus on giving a pathologic diagnosis to humans who are reacting in a human way to an inhumane experience, miss the mark: the entire medical education system needs sweeping change. A toxic construct that has been perpetuated for generations has finally reached a pinnacle in which the very persons who wish to dedicate their lives to keeping others healthy have been sentenced to age six times faster. This is not a problem to be fixed on an individual level. “Destigmatizing” mental health problems and providing access to care is insufficient. We need to redesign our entire approach to educating physicians so that regular therapy isn’t so frequently required just to make it through the week. A good friend and co-resident of mine often says, “We are applying an individual level solution to a system-wide problem.” Enough. Let us change the conversation, aim upstream, and commit to truly healing this broken system.
Rachel Goossen, MD, graduated from the University of Utah Family Medicine Residency Program in June 2019.