Summer is upon us, and with it comes the end of the academic year, graduations and the arrival of the newest crop of interns. Soon these fresh-faced physicians will enter into one of the most remarkable educational experiences of their medical careers: residency. Many of these soon-to-be-interns are looking to attendings now for advice on how to excel during (or survive through) the arduous first year of training. Suggestions like “always make time to read,” “ask for help when you need it,” and “don’t piss off the nurses” are evergreen. An untold number of similar pearls were passed on to me at the end of my fourth year of medical school. The tip that stuck out the most, however, wasn’t one about writing orders or time management or strategic napping. It was the warning that an upper-level resident gave me about what she called “the intern year breakdown.” “Look,” she told me. “Intern year sucks. At some point, you’re going to hate your job and yourself and you’re just going to want to stay in bed and cry all day. But hey. You’ll get through it.” She patted my arm and smiled at me. It provided little comfort.
Sure enough, my intern year was peppered with days where I did feel like hiding in the safety of my bed. Still, I and most of my co-interns and friends from medical school made it through the first half of the year relatively unscathed. Most of us ran on a combination of adrenaline, bewilderment, and caffeine (which seemed to have had a bit of a protective effect) for the first six months. However, as the days became shorter and the shine of a brand new medical degree wore off, we all became somber.
My friends shared less stories about cool procedures that they had done or patients they had seen and more about exhaustion and degradation. Working more than sixty hours a week (on light weeks), chronic sleep deprivation and missing family and friends can all be extremely stressful. On top of that, we had entered into a field that is at once intellectually, physically and emotionally challenging. For some of us, the first time we’d really had to deal with death was the first time pronounced someone. For others, being cursed at or harassed by attendings, nurses, patients and other residents became commonplace. The joy of learning the art of medicine was dampened by a flood of notes and paperwork. Frustration and fatigue were followed by anger, sadness and a profound sense of hopelessness. Some of us thought about quitting. Some of us cried in call rooms. Some of us smoked too much, drank too much, ate too much, just trying to get through it.
I don’t know that any of us reached out to employee health or other mental health services during our respective breakdowns. If someone did, they didn’t talk about it. I certainly thought about it when it was my turn to fall apart. I struggled during my first six months of training and that coupled with self-doubt, several toxic interactions with supervisors and being 12 hours away from my family and closest friends culminated in feelings of worthlessness, sadness, and pessimism. I was lucky. I never had thoughts of suicide but I knew others who had. I promised myself that I would call my hospital’s crisis program if things got that bad. My breakdown lasted a little under two weeks. The feelings resolved, I finished my intern year and blossomed as an upper-level resident.
When I think of intern year now, I tend to think of the best parts first. I fell in love with my specialty and my subspecialty during that year. I will never forget the patients that I met, the calls that I had and the lessons that I learned even as I struggled. I will also never forget about that sadness.
I often think about the advice that resident gave me and how she made what practically amounted to a major depressive episode seem like just one more step in the path to becoming a physician. When did these feelings, these breakdowns, become so ubiquitous? I hardly think that my friends, colleagues, and I are anomalies. I’ve heard similar stories of breakdowns and burnout from people at any stage of a medical career. We physicians have examined our illnesses and the results of recent studies are sobering. We are at higher risk of depression and suicide than the general population. 21 percent of physicians report that they have had depression. 28.8 percent of residents have experienced depression or depressive symptoms during residency. Up to 400 physicians die by suicide each year. It seems like every day new a new study presents a similar or worse picture. Some good news is that physicians and medical students have been sharing their own experiences with illness and burnout more and more frequently. Irrefutable data and unforgettable anecdotes have done a lot to shine a light on something that is hidden far too often.
I am glad that we physicians feel more comfortable talking about our own mental health these days. Hospitals and training programs seem to be more invested in crisis and wellness programs than ever before. I am glad for that too. But I still have to wonder when physicians started to accept profound sadness, guilt, self-loathing and unhealthy coping mechanisms as much a part of training as procedures and textbooks. I think about a piece of advice that my grandfather gave me: something that he learned upon starting his own residency program back in 1954. “You have to pick something,” He said. “Food, liquor, cigarettes or prayer. Pick one and use it to help you get through.” I would like to think that things have changed since then but …
The intern year breakdown comes for many of us. It came for me, and now I feel obligated to warn aspiring physicians about its existence. However, warning them is not enough. We should work to prevent these breakdowns in the first place. Wellness programs may be a start but they are not enough to address the problem completely. Neither are the burnout prevention lectures that trainees have to sit through annually. There may never be adequate solutions for resident sleep problems, duty hours or paperwork overload but there are some things that we can try to address within the medical community. There are growing movements to support physician mental health, to confront harassment and abuse — and to cultivate healthier work environments for trainees and for all of us.
Physicians should support these movements and continue to work for positive change within our profession. If we are less broken down as interns, then maybe we’ll be less likely to burn out by the time we’re attendings.
The intern year breakdown does not have to be inevitable. Burnout does not have to be inevitable. With work and a willingness to change some of the most toxic elements of our culture, maybe someday both will be the exceptions and not the rule.
Diana Cejas is a pediatric neurologist.
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